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ENVIRONMENTAL HtALTH 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 OJ PIPING REPAIR/RETROFIT® UDC REPAIR/RETROFIT 0 COLD STARTiEVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name Unocal Phone 209-473-7337 <br />I <br />1 <br />_ <br />Address 2701 W March Lane Stockton CA 95219 <br />I <br />T <br />Cross Street I-5 <br />Y <br />Owner/Operator Unocal 76 <br />Phone # .209-473-7337 <br />C <br />D <br />Contractor Name Service Station Systems, Inc. <br />Y <br />Phone # 408-213-6038 <br />TContractor <br />Address 680 Quinn Avenue <br />CA Lie #' 485184 CIBSS B C61/D40 HAZ <br />R <br />A <br />insurer Cypress Insurance Company <br />Work COInp# 3310020636091 <br />C <br />T <br />ICC Technician's Name <br />N Bryan Lundien <br />Expiration Date 10/23/2011 <br />o <br />R <br />[CC Installer's Name <br />Expiration Date <br />Tank system Work area <br />ae, 87 Piping swnp. 91 awls deledta, UDC Un, eu l <br />Tank Size <br />Chemicals Stored Currents Date UST <br />y Installed <br />T <br />A <br />N <br />K` <br />P <br />® Approved Approved with conditions Disapproved <br />L <br />&e Attachment With Conditions) <br />A <br />N <br />Pian Reviewers Nam Date7` / I <br />APPLICANT MUST PERFORMORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRON NTAL HEALTH DEPARTMENT. OWNER OR LICENSED' AGENTS SIGNATURE CERTIFIES THE FOLLOWWGt 7 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 WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Compliance Officer Date 3/17/2011 <br />Applicants Signature ladztULL <br />[+.7tR#I II`ic71 1aZi1:4['i'4!�)Li�1l°)? <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 />SIGNATURE�-r,-1 DATE 3/17/2011 <br />EH230038 (revised 02120109) <br />0 <br />