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ENVIRONMENTAL HEALTH DEPARTMENT9 zoos <br />SAN JOAQUIN COUNTY "Ay <br />1HUNMENTAL <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 />TANK RETROFIT D PIPING REPAIR/RETROFIT X UDC REPAIRIRETROFIT IP COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Mark Shaw 916-503-2538 <br />C <br />Facility Name Arco <br />Phone # 209-466-6633 <br />L <br />Address 130 S. Wilson Way <br />1 <br />Cross Street <br />Y <br />Owner/Operator Arco <br />Phone # 209-466-6633 <br />o <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />T <br />RA <br />Contractor Address 680 Quinn Avenue CA Lic # 312844 Classg, C61/D40, Hh <br />Insurer Insurance Company of the West <br />Work Comp # WpL 502190702 <br />GICC <br />T <br />Technician's Name Randy Wilkerson <br />Expiration Date 4/24/2017 <br />RICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC 1Q, e(c.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />A <br />N <br />K <br />P <br />Approved Approved with conditions Disapproved <br />L <br />A <br />(Xtachnnent With Conditions) <br />l' <br />N <br />Plan Reviewers Name Date <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 />Applicant's Signature /- Title Compliance Officer Date 3/25/16 <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 Mark Shaw TITLE Compliance Manager PHONE # 916-503-2538 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE / <br />E <br />EH230038 (revised 02/20/09) <br />1 <br />F 3/25/16 <br />