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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 />CX TANK RETROFIT ❑ PIPING REPAIR/RETROFIT [ I UDC REPAIR/RETROFIT/ft COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />APhone <br />C <br />Facility Name SAFEWAY FUEL CENTER <br />#2600 <br /># <br />L <br />Address (TANKS) <br />1987 WEST 11th <br />STREET <br />Cross Street N. CORRAL HOLLOW ROAD <br />T <br />Y <br />Owner/Operator STAN OLEA c/o SAFEWAY, INC. <br />Phone # 925-467-2707 <br />C <br />Contractor Name MARTY WEITHMAN c <br />o ABLE MAII�T CE <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 QUINN AVE., <br />SAN JOSE, CA CA Lic# 312844 Class B,A,CIO,HAZ <br />R <br />A <br />Insurer <br />Work Comp # <br />TICC <br />Technician's Name <br />Expiration Date <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Chemicals <br />Stored Currently Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />FILL SUMP <br />kTaSize <br />(--AqnT.TNF <br />9n09 <br />T <br />89 TANK ./ <br />A <br />N <br />K <br />❑ Approved <br />❑ Approved with conditions <br />❑ Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK <br />JOAQUIN COUNTY, ENVIRONMENTAL HI <br />THE PERFORMANCE OF THE WORKFO <br />TO WORKER'S COMPENS TION WS� <br />THAT IN THE PERFORMAN TH/EDW <br />OF CALIFORNIA." <br />Applicant's Signature <br />z1— <br />Indicate the responsit <br />the party designated <br />responsibility for the <br />NAME TAN OL A <br />ADDRESS 59/1S7 <br />SIGNATURE <br />ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />LTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />.� <br />Title <br />zI�,o1OCA- <br />�BIW01W11Q_/�.TI ON: <br />la to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />low is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />3 by signature and date below. <br />EH230038 (revised 02/20/09) <br />AY, INC. TITLE OPERATIONS MANAGER PHONE# 925-467-2707 <br />