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 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> D Facility Name Safeway Phone# 209-472-8600 <br /> -Address L Add6425 N Pacific Ave Stockton CA 95207 <br /> TI Cross Street Central Ct <br /> Y Owner/Operator Safeway Inc Phone# 925-467-2707 <br /> 0 Contractor NameService Station Systems, Inc.D Plane# 408-213-6038 <br /> T Contractor 680 Quinn Avenue CA Llc# 485184 Classg C61/D40 HAZ <br /> R <br /> Insurer Travelers Work Comp# UB6054F2133 <br /> T ICC Technician's Name Bryan Lundien Expiration Date 10/23/2011 <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Slored Current) Dale UST <br /> fe arpignsaamp.s+wkaalam�.uoc+rz.exJ y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approved .Approved With conditions I!J Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name <br /> Dale <br /> APPLICANT MUST PERFORM ALL WOR ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL TH 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 TO13ECOMS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 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 /> Appllkanrs Sisnaturel " to 6c a L' k ( C LL ti'TPoe Compliance Officer Data 6/20/2011 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. 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 ' <br /> SIGNATURE l] L,.(StLC-L I U /«L—tcr ,✓ DATE 6/20/2011 <br /> EH230038(revised 02!20109) <br /> 1 <br />