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Ll <br />0 <br />ENVIRONMENTAL HEALTH D,EPARTM,ENT <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 B UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman (408) 213-60 <br />C <br />FacltityNBlvd Shell & Mini Mart <br />Phone# 209-835-7608 <br />� <br />Address racv Blvd.. <br />T <br />Cross Street 1- 205 <br />Y <br />owner/Operator Edwards Oil <br />Phone # 209-835-7608 <br />C <br />Contractor Name Service Station Systems <br />Phone # 408) 213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Class B C61 /D40 HAZ <br />A <br />insurer Cypress Insurance Company <br />Work Camp# 3310020636081 <br />C <br />T <br />QICC <br />ICC Technician's Name Chris McKenna <br />Expiration Date 3/19/2011 <br />R <br />Installer's Name <br />Expiration Dale <br />Tank system work area <br />(i.e 87 piping sump, 91 leak deledor, UDC M etc.) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® App ed Approved with conditions Disapproved <br />L <br />A <br />N <br />is ttachment With Conditions) <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 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 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 />ApplicanrsSignature CL..,"�' ` tc�Tlne uompilance UTrlcer Date 9/14/09 <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 Martv Weithman TITLE Compliance Officer PHONE# (408) 213-6038 <br />ADDRESS 680 Quinn Avenue San Jose, CA 95112 <br />SIGNATURE <br />EH230038 (re' <br />1 <br />9/14/09 <br />