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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,Cafffornia 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 RETROFIT 10 PIPING REPAIR/RETROFIT Ej UDC REPAIR/RETROFIT 0 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&Mini Mart Phone# 209-835-7608 <br /> 1 Address y <br /> L 3725 N Trac Blvd,Trac CA 95376 <br /> I Cross Street 1-205 <br /> T <br /> Y Owner/Operator Shell Oil Products Phone# 209-835-7608 <br /> o Contractor Name Service Station Systems, Inc. Phone# <br /> 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> R A Insurer Cypress Insurance Company <br /> Work Comp# 3310020636091 <br /> TICC Technician's Name <br /> T Bryan Lundien Expiration Data 10/23/2011 <br /> QICG 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 IR,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ej Approved 'Approved With conditions D Disapproved <br /> LAttachment With Conditions) <br /> A <br /> N Pian Reviewers Nam5�7/�O <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN AC DANCE 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: '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 TO"BECOME SUBJECT <br /> TO WORKER'S 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 LAWS <br /> OF CALIFORNIA.' / <br /> Applicanrs Signature , `� �-�X.LL4gz4 Compliance Officer Det, 4/27/2010 <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 IV (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose,95112 <br /> SIGNATURE LLL.44� ✓� ...( Y-L-r!z�(. L�.� DATE 4/27/2010 <br /> EH230038(revised 02120109) <br /> 1 <br />