Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <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 a UDC REPAIRIRETROFIT B COLD START/EVR UPGRAnr- <br />F <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <br />C <br />Facility Name Safeway <br />Phone # 209-830-2950 <br />1 <br />L <br />Address 1987 W 11th st Tracy, CA 95376 <br />T <br />Cross Street Corral Hallow <br />Y <br />Owner/Operator Safeway <br />Phone # 925-467-2707 <br />o <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# B C61/D40 HAZ <br />485184 Class <br />RA <br />Insurer Cypress Insurance Company <br />Work Comp # 3310020636091 <br />cICC <br />T <br />Technician's Name Matt Estabrook <br />Expiration Date 5/28/2011 <br />DICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Dale UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with conditions Disapproved <br />L <br />A <br />Attachment With Conditions) <br />N <br />Plan Reviewers Nam Date D <br />APPLICANT MUST PERFORM ALL WORK IN A RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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.' <br />Appllcanrs Signatures Compliance Officer Date 5/17/2010 <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 />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE- <br />EH230038 (revised <br />1 <br />5/17/2010 <br />