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• <br />• <br />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 />TANK RETROFIT 10 PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Trac Blvd Shell & Mini Mart Phone # 209-835-7608 <br />I <br />I <br />Address 3725 N Tracy Blvd, Tracy 95376 <br />I <br />T <br />Cross Street 1-205 <br />Y <br />Owner/Operator RADC Enterprises <br />Phone # 209-394-4728 <br />C <br />a <br />Contractor Name Service Station Systems, Inc. <br />y <br />Phone # 408-213-6038 <br />TN <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 ClassB C61/D40 HAZ <br />A <br />Insurer ICW Group <br />Work Comp # WPL502130700 <br />c <br />T <br />ICC Technician's Name Jerry Sanouvong <br />Expiration Date 5/2/2014 <br />RICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />{.e. 87 piping sump, 91 leak delecW, UDC in, etc.) <br />Tank Size Chemicals Stored Current) Date UST <br />y Installed <br />T <br />A <br />N <br />K <br />P <br />EjApproved XApproved with conditions ID Disapproved <br />L <br />A <br />(SqeM90ment With Conditions) <br />N <br />Name <br />Pian ReviewersDate <br />APPLICANT MUST PERFORM ALL WORK IN ACCOR E 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 TOSECOME 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />ll <br />Applicanr®Signaturea rde Compliance Officer Dat, 1/21/2013 <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 />1/21/2013 <br />