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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 El PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> c Facility Name Speedway Phone# 209-366-0703 <br /> I Address <br /> L 2500 W Lodi Lodi 95242 <br /> I Cross Street Lower Sacramanto <br /> T <br /> Y Owner/Operator Speedway Phone# 253-896-8809 <br /> oContractor Name Service Station Systems, Inc Phone# 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Ave, San Jose CA 95112 CA Lic# 485184 ClassEl, C61/D40 H/b <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 5021307 <br /> T ICC Technician's Name <br /> T Eusebio(Sammy)Sousa Expiration Date 7/12/2021 <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump,91 leak detector,UDC 12,etc.( y Installed <br /> T <br /> A <br /> N <br /> K <br /> P FJ Approved Approved with conditions CJ Disapproved <br /> L (See Attachment 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: '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.' V,� <br /> Applicanrs Signature q r� �Tide Compliance Officer Date 6/24/20 <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,95112 <br /> 1. <br /> SIGNATURE (�.��y �)` DATE 6/24/20 <br /> EH230038(revised 02/20/09) <br /> 1 <br />