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Jul 22 09 10:18a J.R. Beard 805-540-5241 p.2 <br />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 PERMFT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br />® TANK RETROFIT ❑ PIPING REPAIR/RETROFIT Q UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />r <br />EPA Site # Project Contact Telephone # <br />A <br />a <br />Facility Name SAFEWAY FUEL CENTER #2600 Phone # <br />L <br />Address TALKS) 1987 WEST 11th STREET <br />I <br />T <br />Cross Street N. CORRAL HOLLOW ROAD <br />Y <br />Owner;Operator STAN DLEA c/o SAFEWAY, INC. <br />Phone# 925-467-2707 <br />C <br />Contractor NameMARTY WEITHMAIf c o ABLE CE Phone # 40&-213-6038 <br />N <br />Contractor Address 680 QUINN AVE., SAN JOSE, CA CA Llc# 312844 Class$,A,C10,HAZ <br />T <br />Insurer INSURANCE COMPANY OF THE WEST Work ComPf4PL500060300 <br />T <br />ICC Technician's Name KELLY BURNINGHAM Expiration Date 12/19/2010 <br />°R <br />ICC Installer's Name KELLY BURNINGHAM Expiration Date 12/19/2010 <br />Tank System work area Tank Size Chemicals Stored Currently Date UST <br />Q.e, 57 pPW,g pump. 2% leek deledot, UDC 1R, et.) Installed <br />T <br />' Txg 2002 <br />A <br />N <br />K <br />P <br />El Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Data <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQJIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOACUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOYNNG 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK =0R WNFCH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOYANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO VvORKER'SCOMPEN TION WS OF CA'-IFCRNIA,' CONTRACTOR'S HIRING 0.1 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMA 7HE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />j c� <br />Applkant's SiBnaturo 711. `^ Dale Z l <br />(L;;/ � ��1 TION: - I <br />lndlcate the response le party to be billed for additlonal END 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 STAN 01,FA c/o SAFEWAY. INC. TITLE OPERATIONS MANAGER PHONEA 925-467-2707 <br />SIGNATURE �' CATE I- <br />EH230033 (revised 02/20/08) <br />1 <br />