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' � y <br /> EN IRONMENTA- L HCALTH 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 /> 13 <br /> ELOW8 TANK RETROFIT RJ PIPING REPAIR/RETROFIT 8 UDC REPAIRIRETROFIT B COLD START/EVR UPGRADE <br /> AEPA Site# Project Contact Telephone# <br /> D Facility Name Safeway Phone# r, -Address �j(a `1 Sc) <br /> I � <br /> L 1 `�S �7 _ S�. Tri L <br /> I <br /> Cross Street (,) k,,-L— 1 u <br /> T <br /> Y Owner/Operalor Safeway Inc Phone# 925-467-2707 <br /> c Contractor Name <br /> Q service Station systems, Inc. Phone# ��`� '`3 Sy-7f 1 3 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 C4865 C61/D40 HAZ <br /> R Insurer <br /> CC cess Insurance Company Work Comp# 3310020636 I J I <br /> T ICC Technician's Name �� v) l 1 Expiration Date S '/13 <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area ITank Size Chemicals Stored Current) Date UST <br /> I.e. pn.,oSUMP.s,wk etl.aw,,utic Q kc) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Pian Reviewers NameDate 06 0-111 <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 WN1CH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO-BECOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA.' GONTRACTOR'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 /> Appilunraftneture � 1 _�_ Compliance <br /> Dale <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for addriional EHD staff time expended beyond permit payment coverage per lank. If <br /> the party designated below Is different than the permit applicant, e.g. property owner, the party must acknowiedge this <br /> responsibilly for the billing by signature and date below. <br /> NAMEn <br /> _ ay\-J,:e L-> �Z TITLE Compliance (, r' <br /> PHONE#� � �� 7��-"SJ/1 <br /> ADDRESS 680 Quinn Ave. San Jose,95112 <br /> SIGNATURF � �� DATE <br /> EH230038(revised 0200109) <br /> 1 <br />