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SQ N.,J O A Q!�+I I N Environmental Health Department <br /> COUN , <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# Christina Tran 408-213-6039 <br /> A Facility Name Safeway Phone# <br /> C Y Y 209-472-8600 <br /> I <br /> L Address <br /> TCross Street <br /> Y Owner/Operator Safeway, Tyler Olea Phone# <br /> c Contractor Name Phone# 707-545-5522 <br /> o Able Maintenance, Inc <br /> N tonal Contractor Address 3224 Re Parkway, Santa Rosa, 95403 CA Lic# <br /> T g� y 312844 Class g q C10 HAZ <br /> A Insurer Praetorian Insurance Company Work Comp# <br /> 204000064 <br /> c ICC Technician's Name Expiration Date <br /> T see attached P <br /> RICC Installer's Name see attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L (See ttachment With Conditions) <br /> A <br /> N 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: "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." I v//y/Z-3 <br /> �Applicant's Signature Tile P r Date ` LtJ L� <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 /> NAME Christina Tran TITLE Project and Permit Coordinator PHONE# 408-213-6039 <br /> ADDRESS 680 Quinnn Ave,San Jose Ca 95112 <br /> SIGNATURE "A�L' DATE <br /> 3of6 <br />