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0 0 RGEIVED <br />ENVIRONMENTAL HEALTH DFPARTMENTPR SAN JOAQUIN COUNTY 0 3 205 <br />600 East Main Street, Stockton, California 95202 ENVIRONMENTAL. <br />Telephone: (209) 468-3420 Fax: (209) 468.3433 HFA! ri;4 nrPAPTAAPKIT <br />APPLICATION FOR UNDERGROUND STORAGE TALK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />8 TANK RETROFIT Id PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT 11 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <br />C <br />Facility Name Unocal <br />Phone # 209-473-7337 <br />1 <br />L <br />Address 2701 March Lane, Stockton CA 95219 <br />1 <br />T <br />Cross Street 1-5 <br />Y <br />Owner/Operator Darren Eppler <br />Phone # 209-473-7337 <br />oContractor <br />Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 312844 Glassg, C61/D40, Haj <br />A <br />insurer Insurance Company of the West <br />Work Comp # WPL 502190702 <br />T <br />ICC Technician's Name Michael Thomas <br />Expiration Date 4/29/2016 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date (1ST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with conditions C3 Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name_ CK.���✓ til r-1 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 WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />� <br />61IL4�-` Alttt�,L-ILL-fk-I-'rft Compliance Officer 4/1/2015 <br />ApplicanrsSigneturej Date <br />BILLING INFORMATION: <br />Indicate the responsibleparty 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 68)0 Quinn Ave. San Jose, 95112 <br />SIGNATURE DATE 4/1/2015 <br />EH230038 (revised 02/20/09) <br />1 <br />