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ENVIRONMENTAL HEALTH D.EPA'RT <br /> � 6EI <br /> SAN JOAQUIN COUNTY VED <br /> 600 East Main Street, Stockton, California 95202 OCT 0 9 2014 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING SLP , I! ,�TH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Safeway Phone# 209-830-2950 <br /> 1 Address y <br /> L 1801 W 11th St Trac CA 95376 <br /> I Cross Street Corral Hallow <br /> T <br /> Y Owner/Operator Safeway Inc Phone# 925-467-2707 <br /> C Contractor Name Service Station Systems, Inc Phone# <br /> 0 Y 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Ave, San Jose CA 95112 CA Lic# 485184 Class g, C61/D40 <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL502130702 <br /> cICC Technician's Name <br /> T Sammy Sousa Expiration Date 4/16/2016 <br /> ' <br /> R ICC Installers Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i a 87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K ° L <br /> P FJ Appr ved 4ettechment <br /> roved with conditions 0 Disapproved <br /> L With Conditions) <br /> A <br /> N Plan Reviewers Name 7 Date <br /> _J0_k7 <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 WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'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 /> Applicants SlgnaWre Compliance Officer Dare 10/7/2014 <br /> BILLING INFORMATION: <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 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 Marty Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 68/0 Quinn Ave.San(Jose, 95112 ,�Q� <br /> SIGNATURE j L'(Com, VI '`�'e �—�� DATE 10/7/2014 <br /> EH230038(revised 02/20/09) <br /> 1 <br />