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RECEIVED <br /> ENVIRONMENTAL HEALTH ®.EPARTM"'F4 2018 <br /> SAN JOAQUIN COUNTY elvvlliown►►,N.►.,`► ►1►'::�►:r►► <br /> 600 East Main Street, Stockton, California 95202 1)vp.,%RI"SII., I' <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT E PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Rales Phone# 209-956-9300 <br /> 1Address <br /> L 4219 Morada Lane, Stockton CA 95212 <br /> TCross Street <br /> Y Owner/Operator Raleys Phone# 916-373-6325 <br /> C Contractor Name Able Maintenance Phone# <br /> 0 408-213-6038 <br /> N Contractor Address <br /> T 3224 Regional Pkwy, Santa Rose CA 95403 CA Lic# 312844 Classg,A,C10 <br /> R Insurer <br /> A State Comp Ins Fund Work Comp# 8073129 <br /> C ICC Technician's Name <br /> T Expiration Date <br /> D ICC Installer's Name <br /> R Kell Burningham Expiration Date 1/20/2019 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e 87 piping sump.91 leak detector,uoc 1R,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions [n Disapproved <br /> L (SekeA achment With Conditions) <br /> A <br /> N Plan Reviewers Name Q. LO , vl Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' r <br /> ApplicanrsSignalure cc.. v�:�l • -f= +-t-r Itle Compliance Officer Da3ce 5/17/2018 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE# 408-213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose,95112 <br /> SIGNATURE `l. Ct l l t ���, I A�(-L d to L c�� DATE 5/17/2018 <br /> '( <br /> EH230038(revised 02/20/09) <br /> 1 <br />