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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: L TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT f] COLD START/EVR UPGRADE F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 A C Facility Name Safeway Phone # 209-830-2950 1 L Address y 1987 W 11 th Street, Trac CA 95376 1 T Cross Street Corral Hallow Y Owner/Operator Safeway Inc. Phone # 925-467-2707 o Contractor Name Service Station Systems, Inc. Phone # 408-213-6038 NContractor T Address 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ RA Insurer Cypress Insurance Company Work Comp # 3310020636091 cICC T Technician's Name Matt Estabrook Expiration Date 5/28/2011 QICC R Installer's Name Expiration Date Tank system work area (i.e 87 piping sump, 91 leak detector, UDC IQ, etc.) Tank Size Chemicals Stored Current) y Date UST Installed T A N K P Approved Approved with conditions Ll Disapproved L A (Se ment With Conditions) N Plan Reviewers Namcis—,: Date APPLICANT MUST PERFORM ALL WORK IN AC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN 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 TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' 1 , v '��itle Compliance Officer 6/29/10 Applicants Signature' Dei BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Marty Weithman TITLE Compliance Officer PHONE # (408) 213-6038 ADDRESS 680 Quinn Ave. San Jose, 95112 SIGNATURE -Z DATE 6/29/10 EH230038 (revised 02/20/09)