Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 <br /> Telepbone: (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 REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> O Facility Name Safeway Phone# 209-472-8600 <br /> -Address L Add6425 N. Pacific Ave Stockton CA 95207 <br /> 1TCrossStreet Central St <br /> Y Owner/Operator Safeway Inc. Phone# g25-467-2707 <br /> o Contractor Name Service Station Systems, Inc. Phone# <br /> 408-213-6038 <br /> iContreclorAddresa 680 Quinn Avenue CA Lie# 485184 ClaesB C61/D40 HAZ <br /> RA Insurer Cypress Company <br /> Work COMP 111 3310020636091 <br /> D ICC Technician's Name <br /> T Rand Wilkerson Expiration Date 5/26/2011 <br /> R ICC Installers Name Expiration Date <br /> Tank system work area <br /> ( Tank Size Chemicals Stored Curren! Date UST <br /> ..a Bl gpinp dump,pl We detector.UDC 1/t,aaJ N Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approved Approved With conditions Disapproved <br /> L (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Na <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 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 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Apglcanra Sgnelure ZLat, �/ aA ftc Compliance Officer Dela 6/17/2010 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff lime 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,9511 112 <br /> SIGNATURE jAjiL 1ZA.- \J- �V DATE 6/17/2010 <br /> EH230038(revised 0220109) <br /> 1 <br />