Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton , California 95202 s� <br /> Telephone : (209) 468-3420 Fax : (209) 468-3433' <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT �R PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PER IT TYPE BELOW : <br /> 8 TANK RETROFIT PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETRO IT COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Safeway #2600 Phone # <br /> 209-830-2950 <br /> I Address <br /> L 1987W 11th St , Tracy CA 95376 <br /> TCross Street <br /> Y Owner/Operator Corral Hallow Phone # 925-467-2707 <br /> CContractor Name Service Station Systems , Inc Phone # 408-213-6038 <br /> T Contractor Address 680 Quinn Ave , San Jose CA 95112 PA Lic # 485184 ClassB C61 /D40 <br /> lolls <br /> A Insurer Insurance Company of the West Work Comp # WPL 5021307 <br /> T ICC Technician's NameExpiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Dale UST <br /> (Le 87 piping sump, 91 leak detector, UDC 1n, etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P FEJ Approved Appr ved with conditions 12 Disapproved <br /> L (See Attachment With Conditions ) <br /> A I <br /> N Plan Reviewers Name 1 Date <br /> i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA UIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER Off 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'# HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.` <br /> Applicant's Signature �h -k. <br /> kec -Gti L ,.Tloe/ Compliance Officer Date 6/21 /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 . 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 , 951112 <br /> SIGNATURE IM qA�tt &L2 " `'� ' DATE 6/21 /2019 <br /> EH230038 ( revised 02/20/09) <br /> 1 <br />