Laserfiche WebLink
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 E PIPING REPAIR/RETROFIT ),UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br /> FfAdcrBSsN864e25 <br /> EPA Ste# Project Contact 6 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> cFailitmSafeway Phone# 209-472-8600 <br /> L N. Pacific Ave Stockton CA 95207 <br /> 1 Cross Street Central Ct. <br /> T <br /> Y Owner/Operator Safeway(Stan Olea) Phone# 925-467-2707 <br /> C Contractor Name <br /> G Able Maintenance, Phone# 707-545-5522 <br /> N Contractor Address <br /> T 3224 Regional Parkway,Santa Rosa 95403 CA Llc# 312844 Claes B A C10 HAZ <br /> RInsurer <br /> A Insurance Company of the West Work Comp# yypL500060300 <br /> T ICC Technician's Name <br /> Expiretlon Date <br /> R ICC Installer's Name Mike Tre'o Expiration Date <br /> 4/17/2011 <br /> Tank system work area Tank Size Chemicals Stored Curren Date UST <br /> lis 87 piping amp,91 lsak aataplOf,UDC IR,m.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ®Approved ftApproved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Nam Date — 2 <br /> Date_ <br /> APPLICANT MUST PERFORM ALL WO/RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS 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 TD BECOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS 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 RT WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.'Signat <br /> Appllpanra ure`q <br /> 1' ea` f v• Compliance Officer pats 3/24/10 <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,915,112• .�. <br /> SIGNATURE l/LIQ.(..L.�A.LL V - 71�-C�al�t�] ATE 3/24/10 <br /> EH230038(revised 0220/09) <br /> 1 <br />