Laserfiche WebLink
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 IN DAYS FROM THE APPROVAL DATE_ INDICATE PERMIT TYPE BELOW: <br />Q TANK RETROFIT ® PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT fj COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />D <br />Facility Name Trac Bivd Shell and Mini Mart Phone # 209-835-7608 <br />I <br />L <br />Address 3725 N Tracy Blvd, Tracy CA 95376 <br />I <br />T <br />Cross Street 1-205 <br />Y <br />Owner/Operator RADC Enterprises <br />Phone # 909-394-4728 <br />C <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Class B C61 /D40 HAZ <br />R <br />A <br />Insurer ICW Group Work Comp # WPL502130700 <br />T <br />ICC Technician's Name Steve Parmenter Expiration Date 3/29/2015 <br />o <br />R <br />ICC Installer's Name Expiration Date <br />Tank system work area <br />0-e. 67 piping sump, 91 ink dek , UDC 1l2, etc.) <br />Tank Size Chemicals Scored Currently <br />'J <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />®Approved Approved with conditions M Disapproved <br />L <br />A <br />( S A achment With Conditions) <br />N <br />�} <br />Plan Reviewers Name_ 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 AGENTS 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 1N 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 />Appllcenrs SIg„al,xe Compliance Officer Date 4/8/2013 <br />• *N <br />Indicate the responsible parry 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 �' LL' ` 4/8/2013 <br />DATE <br />EH230D38 (revised 02=109) <br />1 <br />