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ENVIRONMENTAL HEALTH 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 /> 8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT B UDC REPAIR/RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> C Facility Name Gas 4 Less Phone# <br /> 209-234-7889 <br /> Address <br /> L 3434 Manthey Rd, Stockton CA 95206 <br /> TCross Street <br /> Y Owner/Operator Jesus Jurado Phone# <br /> 209-858-0101 <br /> c Contractor Name Service Station Systems, Inc. Phone# <br /> o Y 408 213-6038 <br /> NContractor Address <br /> T 680 Quinn Avenue CA Lic# 312844 Classg, C61/D40, Hill <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 502190702 <br /> cICC Technician's Name <br /> T Robert Murdoch Expiration Date 7/16/2017 <br /> QICC Installer' N <br /> R same Expiration Date <br /> Tank system work area Tank Size Chemicals Stared CurrentlyDale UST <br /> (i a 87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P F3 Approved pproved with conditions M Disapproved <br /> L Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> Y <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 FCLLOWING: '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 Signature, - tiy. - L.L TU Compliance Officer Dace 9/3/2015 <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 4 (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose, 95112 <br /> SIGNATURE�.^� Q14 .177F, v�I " - :.��P�� DATE 9/3/2015 <br /> EH230038(revised 02/20/02) <br /> 1 <br />