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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUN'T'Y <br /> 600 East Main Street, Stockton , California 95202 <br /> Telephone : (209) 468-342Q 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 REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> c Facility Name H & M Market Kwik Serv) Phone # 209-838-3971 <br /> I Address <br /> L 2501 Jackson Ave , Escalon CA 95320 <br /> TCross Street <br /> Y Owner/Operator Boyette Petroleum Phone # 209-549-5612 <br /> C Contractor Name Able Maintenance Phone # <br /> 0 408-213-6038 <br /> Contractor Address <br /> TN 3224 Regional Pkwy , Santa Rose CA 95403 CA t_ic # 312844 ClassB ,A, C10 <br /> R Insurer <br /> A State Comp Ins Fund Work Comp # 8073129 <br /> T ICC Technician's Name Expiration Date <br /> Q ICC Installer's Name Expiration Date 1 (4a !" 2. 1 <br /> R Kell Burningham p � � . <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> Wt(Le 87 piping sump, 91 leak detector, UDC , etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name ' DateI�— <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 AGENT'S 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 TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: Ni 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.' v� <br /> Applicant's S1gnalure % xW t'Ly ` 404 tllue Compliance Officer Date ` B Z- 0 / <? <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 '� ..btu DATE <br /> EH230038 (revised 02/20/09) <br /> 1 <br />