Laserfiche WebLink
ENVIRONMENTAL HEALTH D :EPA'RTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton , California 95202 <br /> Telephone : (209) 468-3420 Favi ; (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 PIPING REPAIRIRETROFIT UDC REPAIR/RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Safeway #2707 Phone # <br /> 209-472-8600 <br /> I Address L Add6425 N Pacific Ave <br /> Cross Street Central St <br /> T <br /> Y Owner/Operator Aldo Basurto (Safeway/Albertsons) Phone # <br /> 925- 580-8131 <br /> C Contractor Name Service Station Systems Inc Phone # <br /> o Y 408-213-6038 <br /> T Contractor Address 680 Quinn Ave , San Jose CA 95112 CA Lic # 485184 Class <br /> 13 C61 /D40 HAZ <br /> AInsurer Work Comp # <br /> c ICC Technician's Name <br /> T Expiration Date <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (Le 87 piping sump, 91 leak detector, UDC M, etc.) y Installed <br /> T 104 <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> A 0 <br /> N Plan Reviewers Name ` <br /> 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 : '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 : "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 /> t <br /> , j <br /> Applicanfa Signature r� tt� Title Compliance Officer Date 1 /25/2023 <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- -Qt.�-L' v ' " u '�' �'� � � DATE 1 /25/2023 <br /> EH230038 (revised 02/20/09 ) <br /> 1 <br />