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Environmental Healin Department <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTJEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact &Telephone if Christina Tran 408-213-6039 <br />AC <br />Facility Name Poppy Markets <br />Phone # 209-939-1755 <br />L <br />Address 713 N EI Dorado St, Stockton, CA 95201 <br />TCross <br />Street <br />Y <br />Owner/Operator <br />h: <br />Phone # <br />o <br />Contractor Name Service tation S stems, Inc 4 <br />c. <br />Phone # 408-971-2445 <br />T <br />Contractor Address 680 Quinn Ave, San Jose, CA 95112 <br />CA Lie # 485184 Class BC61/D40 HAZ <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WLV507821801 <br />T <br />ICC Technician's Name see attached <br />Expiration Date <br />oICC <br />R <br />Installer's Name <br />Expiration Date <br />P <br />see attached <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />T <br />r <br />A <br />_ <br />N <br />K <br />PApproved <br />with conditions <br />❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name__ q -f \)o � �- <br />Date 0/2 IN Poll <br />_AA� <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 <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE <br />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 TH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />, ? <br />Applicant's <br />Signaturee� ���•����✓" Title Permit and Project Coordinator Date 2/6126 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed far 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 parry must <br />acknowledge this responsibility for the billing by signature and date below. <br />NAME Christina Tran TITLE Permit and Pro <br />ADDRESS 680 Quinn Ave,aSan Jose, CA 95112 <br />6'MUTT <br />ject Coordinator PHONE # 408-213-6039 <br />TE 2/6/26 <br />