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SANJOAQUIN Environmental Health Department <br /> COUNTY— <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Brian Able - 408-938-7116 <br /> Facility Name Speedway Phone # 209-939-9295 <br /> I Address L Add2705 Country Club Blvd . Stockton , Ca 95204 <br /> 1 Cross Street Highway 5 <br /> Y Owner/Operator Speedway LLC Phone # 209-939-9295 <br /> c Contractor Name Service Station Systems Inc. Phone # 408-971 -2445 <br /> 0 <br /> N <br /> T Contractor Address 680 Quinn Ave. San Jose , CA 95112 CA Lic # 485184 Class B/C-61 /D40/1-11a <br /> Insurer awti Work Comp # 4o LI ( ` v 3 <br /> A W C, F I�a%hb wu�\ I w <br /> c ICC Technician's Name Kris Bell <br /> T Expiration Date 07/22/2024 <br /> R ICC Installer's Name Kris Bell Expiration Date 07/22/2024 <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 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ffI <br /> N Plan Reviewers Name l % ' I ` 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 TO <br /> 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 /> Applicant's Signature Title Project Manager Dale 05/15/2023 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e , g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> Brian Able Project Manager 408 - 938 - 7116 <br /> NAME TITLE g PHONE # <br /> 680 Quinn Ave . San Jose, Ca 95112 <br /> ADDRESS <br /> SIGNATURE L DATE 05 /22 /23 <br /> 2 of 6 <br />