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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 /> 10 TANK RETROFIT [0 PIPING REPAIRIRETROFIT [I UDC REPAIRIRETROFIT [] COLD START1EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> c Facility Name Mobil Phone# 209-368-8787 <br /> IAddress <br /> L 401 W Kettleman Lane <br /> I Cross Street Hutchins <br /> T <br /> Y Owner/Operator Elizabeth Okupe Phone# 209-231-9130 <br /> I <br /> t <br /> S <br /> Nam <br /> t <br /> t <br /> C <br /> C Contractor e Service Station Systems, Inc.0 Phone# 408-213-6038 <br /> N T ----FCA Lie# 485184 <br /> Contractor Address 680 Quinn Avenue CIaSsB, C61/D40, Hlh <br /> R <br /> A Insurer Insurance Company of the West Work Comp# WPL 5021907 04 <br /> C <br /> T ICC Technician's Name Michael Briggs Expiration Date 5/30/2019' <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date LIST <br /> (i.e 97 piping sump.911 leak detector,UDC U2,etc,) Installed <br /> T <br /> A <br /> N <br /> K <br /> P I^O Approved J0 Approved with conditions D Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Z,Date_.._�/OVA? <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 AGENTS 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 70 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicants Signature Compliance Officer Date 2/20/2018 <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 /> NAMEMartyWeithman TITLE Compliance Officer PHOINE# 408-213-6038 <br /> ADDRESS 680 Quinn Ave.San Jose, 95112 <br /> SIGNATURE DATE 2/20/2018 <br /> EH230038(revised 02120109) <br />