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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 /> TANK RETROFIT Id PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Facility Name Food 4 Less(Gas 4 Less) Phone# 209-234-7869 <br /> IAddress <br /> L 3434 Manthey Rd, Stockton CA 95206 <br /> TCross Street <br /> Y Owner/Operator Gilbert Silva Phone# <br /> 209-858-0101 <br /> C Contractor Name Service Station Systems, Inc. Phone,4 <br /> o Y 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> A Insurer ICW Work Comp# WPL502130701 <br /> G ICC Technician's Name <br /> T Kris Bell Expiration Date 10/2/2014 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i a 87 piping sump,91 leak detector,UDC Ir.,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Fj Approved Approved with conditions 0 Disapproved <br /> L (See Ichment With Conditions) <br /> A <br /> N 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: '1 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.' I <br /> Applicant's Signature ( + l �Lj ttt(t(,tt ' ' Tfuo Compliance Officer Date 2/24/2014 <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 680QuinnAve. San Jose, 95112 <br /> SIGNATURE �c�( <� `�l J � u—��L DATE 2/24/2014 <br /> EH230038(revised 02/20/09) <br /> 1 <br />