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i 0 <br />ENVIRONMENTAL HEALTH DEPART WEIVED <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 DEC 0 2 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468.3433 <br />ENVIRONMENTAL <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPINd 'P*WftWWT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />® TANK RETROFIT 10 PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT 1 COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Tracy Blvd Shell & Mini Mart <br />Phone # 209-835-7608 <br />1 <br />L <br />Address 3725 N. Tracy Blvd Tracy, Ca. <br />TCross <br />Street <br />Y <br />Owner/Operator Anabi <br />one # 909-394-4728 <br />o <br />Contractor Name Service Station Systems <br />Phone # 408-213-6038 <br />N <br />T <br />RInsurer <br />Contractor Address 680 Quinn Ave <br />CA Lie # 485184 Class g,C61/D40 I -b <br />A <br />Insurance Company of the West <br />Work Comp # WPL502190702 <br />C <br />T <br />DICC <br />ICC Technician's Name Mike Thomas <br />Expiration Date 4/12/2015 <br />R <br />Installer's Name Mike Thomas <br />Expiration Date 4/12/2015 <br />Tank system work area <br />{i.e. B7 piping sump, 91 Irak detector, UDC 1R, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />LD <br />A <br />N <br />K <br />ILL— <br />'— <br />L <br />P <br />EJ Approved Approved with conditions Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Pian 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: 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 'I <br />FOLLOWING: CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />ApplicanrsSignature Title Compliance Officer Data 11/25/2014 <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 <br />EH230038 (revised 02/20/09) <br />1 <br />11/25/2014 <br />