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ENVIRONMENTAL HEALTH DEPARTMENT ���'�� <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 JUL 0 2 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT T <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT EJ PIPING REPAIR/RETROFIT [I UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br /> F <br /> A EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> Facility Name Gas 4 Less Phone# 209-234-7869 <br /> IAddress <br /> L 3434 Manthey Rd, Stockton CA 95206 <br /> TCross Street <br /> Y Owner/Operator Jesus Jurado Phone# 209-992-1463 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> Q y 408-213-6038 <br /> N Contractor Address 312844 Class <br /> B,680 Quinn Avenue CA Lic# B, C61/D40, Hh <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 502190702 <br /> cICC Technician's Name <br /> T M ke Briggs Expiration Date 6/11/17 <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC ill,etc.) y Installed <br /> T <br /> A <br /> N <br /> K , <br /> P Approved0 Approved with conditions Disapproved <br /> L (See Ghment With Conditions) <br /> A <br /> N Plan Reviewers Name <br /> 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.'�jq <br /> Applicant's Signatur l-(et(- �,�L �L L Tlue Compliance Officer Date 7/1/2015 <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# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose, 95112 1 <br /> SIGNATURE I) DATE 7/1/2015 <br /> EH230038(revised 02/20/09) <br /> 1 <br />