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ENVIRONMENTAL HEALTHDEPART460"0111111`1111--- <br /> SAN JOAQUIN COUNTY JUL 2 9 2016 <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 /> 8 TANK RETROFIT10 PIPING REPAIRIRETROFIT Ej UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> c Facility Name Tracy Blvd Shell and Mini Mart Phone# <br /> 209-835-7608 <br /> 1 Address <br /> L 3725 N Tracy Blvd,Tracy CA 95376 <br /> I Cross Street 1-205 <br /> T <br /> Y Owner/Operator RADC Enterprises Phone# 909-394-4728 <br /> o Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 Class <br /> B, C61/D40, Hlb <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 5021907 04 <br /> T ICC Technician's Name Kris Bell Expiration Date 7/11/2016 <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K 'LI % <br /> P Approved _A2L}lpproved with conditions Disapproved <br /> L (See A7hment With Conditions) <br /> A <br /> N Plan Reviewers Na t--- Date <br /> APPLICANT MUST PERFORM ALL CRK 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: 9 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:'1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,l SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> /«C c+_ G - 1 •' ���'t t"°C Ott{, Compliance Officer 7/28/2016 <br /> Applicants Signature d,, Compliance Date <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 �'L'��� VL`�" fes`' �``'�ti`�' -'�—" DATE 7/28/2016 <br /> EH230038(revised 02/20109) <br /> 1 <br />