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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUN'T'Y <br />600 East Main Street, Staeltton, 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 REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT [I COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone -4 Marty Weithman 408-213-6038 <br />c <br />Facility Name_Safeway #2600 Phone 209-830-2950 <br />I <br />L <br />Address 1987 W 11th St Tracy CA 95376 <br />1 <br />T <br />Cross Street Corral Hallow <br />Y <br />Owner/Operator Safeway Phone .# 9257467-2707 <br />C <br />0 <br />Contractor Name Able Maintenance Phone 408-213-6038 <br />N <br />T <br />Contractor Address 3224 Regional Pkwy, Santa Rose CA 95403 CA Lic # 312844 Cl8ssg,A,C10 <br />RInsurer <br />A <br />State Comp Ins Fund VJork:Comp# 9073129 <br />C <br />T <br />ICC Technician's Name Expiration Date <br />oICC <br />R <br />installer's Name Kelly Burningham Expiration bate. 1/2012019 <br />Tank system work area Tank Size Chemicals Stored Current/ Date UST <br />(Le 87 piping sump, 91 leak detector, UDC 12, etc.) - y Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved'with conditions Disapproved <br />L <br />(See Attachment With Conditions), <br />A <br />N <br />11�� <br />Plan Reviewers Name. �. Q.�� �� Dae (0 ' <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 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- AWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR:SU13CONTRAETING SIGNATUREZERTIFIES THE FOLLOWING: 'I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSAT16N LAWS <br />OF CALIFORNIA.' <br />/ <br />Applicant's Signature fit. LL,_ V Compliance Officer Data 6/10/18 <br />a.a, ..w,.w ur, vrvnn rwr. <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 dffferent than the permit applicant, 6.9, 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-``�ll�� <br />EH230038 (revised 02/20/09) <br />1 <br />6 <br />6/10/18 <br />.F'�. U t'!`^1,.kY ,itr;,=_t•'+ i �-..... '( aUiL.f , <br />