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• • <br /> ENVIRONMENTAL HEALTH DIEPART a . EIV L <br /> SAN JOAQUIN COUNTY AUG 2 7 2015 <br /> 600 East Main Street, Stockton, California 95202 f=NVIRONMENTAL <br /> Telephone; (209) 468-3420 Fax: (209) 468-3433 ,rrc,T,J�C?A�TAACl11T <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 a COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Facility Name Unocal 76#255886 Phone# <br /> 209473-7337 <br /> 1 Address <br /> L 2701 March Lane, Stockton CA 95219 <br /> I Cross Street 1-5 <br /> T <br /> Y Owner/Operator Darren Eppler Phone# 209-473-7337 <br /> oContractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 312844 ClassB, C61/D40, Htj <br /> R Insurer <br /> A Insurance Company of the West Work Camp# WPL 502190702 <br /> T ICC Technician's Name Randy Wilkerson Expiration Date 4/24/2017 <br /> a ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.97 piping sump,91 leak detector,UDC U2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions 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: "1 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." t <br /> Applicants Signalure'W(L i-,b,L,��1"�Lti( c tUe Compliance Officer Data 8/25/2015 <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 /> SIGNATURE �� �t, �,v �,�c _�e::rJ DATE 8/25/2015 <br /> EH230038(revised 02/20/09) <br /> 1 <br />