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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton , California 95202 <br /> Telephone : (209) 46&3420 Fax : (209) 4683433 <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 ID PIPING REPAIR/RETROFIT a UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Unocal 76 Phone # <br /> 209-473 -7337 <br /> I Address L Add2701 W March Lane <br /> i Cross Street 1 - 5 <br /> T <br /> Y Owner/Operator Darren Eppler Phone # 209-973-7337 <br /> c Contractor Name Able Maintenance , Inc Phone # <br /> 0 408 213-6038 <br /> N Contractor Address <br /> T 680 Quinn Ave , San Jose CA 95112 CA Lic # 312844 Classg ,A , C10 HAZ <br /> AInsurer Work Comp # <br /> C ' <br /> ICC Technicians Name <br /> T Expiration Date <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current ) Date UST <br /> (i.e 87 piping sumV20p, 91 leak deteclor, u�c , etc.) y Installed <br /> T <br /> UDC `-i <br /> N <br /> K <br /> P Approved Approved with conditions 0 Disapproved <br /> L (See Attachment With Conditions ) <br /> Nc 2 ZC� <br /> Plan 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 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 : 41 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 /> ApplicantsSignalure I' f ' U � '1 '� ' � k'ee 'l: t � t �-�Tnle Compliance Officer 1 /19/2023 <br /> Date <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 /> s �t _ , a <br /> SIGNATURE � 4- �,�� � t. �; -�LL6-- L� DATE 1 / 19/2023 <br /> EH230038 (revised 120/09) <br /> 1 <br />