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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 /> 8 TANK RETROFIT E PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT 8 COLD STARTlEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Facility Name Safeway Phone# 209-472-8600 <br /> IAddress <br /> L 6425 N Pacific Ave Stockton CA 95207 <br /> T <br /> Cross Street Central Ct <br /> Y Owner/Operator Stan Olea Phone# <br /> 925-467-2707 <br /> o Contractor Name Able Maintenance, Inc. Phone# <br /> 707-545-5522 <br /> T Contractor Address 3224 Regional Parkway, Santa Rosa 95403 CA Lie If 312844 Class g A C10 HAZ <br /> R A Insurer Insurance Company <br /> of the West Work Comp# WpL500060303 <br /> DICC Technician's Name <br /> T Expiration Date <br /> QICC Installer's Name <br /> R Robert Murdoch Expiration Date 8/16/2013 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> Ii e m Ppin S.P.gl wk cf Ua ,UDC IQ,eaJ y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved pproved with conditions In Disapproved <br /> L (See A achmenl With Conditions) <br /> A i <br /> N Plan Reviewers Name � � d"�57 <br /> a Date <br /> APPLICANT MUST PERFORM A{,LWORK 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 IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' 1( <br /> Applicants Signalure7il✓, It Lr Lc�1° I��'trtL LLL&«. Title Compliance Officer Dere 11/17/2011 <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,,,951122 <br /> SIGNATURE 11. { LiI_4-L✓ DATE 11/17/2011 <br /> EH230D38(revised 0220!09) <br /> 1 <br />