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i <br /> ENV16� ® NMMENTAL HEALTH U .EP 'RTENT <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 /> 8 TANK RETROFIT PIPING REPAIR/RETROFIT B UDC REPAIR/ RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A Facility Name Phone # <br /> C Y Manteca Cruisers 209-824-2760 <br /> I Address L Add1137 W Lathro Rd <br /> TCross Street <br /> Y Owner/Operator Monica Farhat Phone # 209 -549-5612 <br /> DContractor Name Able Maintenance Phone # <br /> 0 408-213-6038 <br /> T Contractor Address 3224 Regional Pkwy , Santa Rose CA 95403 CA Lie # 312844 Classg ,A, C10 <br /> R Insurer <br /> A State Comp Ins Fund Work Comp # 8073129 <br /> T ICC Technician's Name Expiration Date <br /> DICC Installer's Name <br /> R Kelly. Burningham Expiration Date 1 /06-2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le 87 piping Sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A G <br /> N <br /> K Ouvk�/ 11 <br /> L <br /> P Approved kA <br /> pproved with conditions 0 Disapproved <br /> L (Seeachment With Conditions ) <br /> A (r1l Q <br /> N Plan Reviewers Name_ 0 �Q � Date vl <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 : '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.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : 01 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.' c ' <br /> ApplicanrsSignature `7/(kO mkoX%-'� f � til -t �- Ttue Compliance Officer Date 3/6/2019 <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 .9 , 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 68�0/Quinn Ave . San �Jose , 95112 <br /> SIGNATURE K " DATE <br /> EH230038 ( revised 02/20/09) <br /> 1 <br />