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A, <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 El PIPING REPAIRIRETROFIT ® UDC REPAIR/RETROFIT Q COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Harlan Shell <br />Phone# 209-403-3859 <br />I <br />L <br />Address p <br />16500 S Harlan Rd, Lathrop CA 95330 <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # 209-403-3859 <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 ClassB C61/D40 HAZ <br />R <br />Insurer ICW <br />Work Comp # WPL502130701 <br />T <br />ICC Technician's Name Gabe Padilla <br />Expiration Date 6/7/2015 <br />oICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area Tank Size Chemicals Stored Current <br />(Le. 87 piping aemp, gt Risk aetecta, UDC 1/2, etc.) ty <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />EjApproved EJ Approved With conditions 0 Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Pian Reviewers Nam® Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAOUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: •I 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 WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS 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 t AWS <br />OF CALIFORNIA." <br />Applicant's signature Tie Compliance Officer s 11/12/2013 <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 DATE 11/12/2013 <br />EH230038 (revised 02/26/09) <br />0 <br />