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SAN, <br /> 1 fi: 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 REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTJEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Christina Tran 408-213-6039 <br /> A Facility Name Po Markets Phone# <br /> C Y PPY 209-939-1755 <br /> I Address 713 N El Dorado St, Stockton, CA 95201 <br /> TCross Street <br /> Y Owner/Operator h: Phone# <br /> o Contractor Name Service tation S stems, Inc 4 c. Phone# 408-971-2445 <br /> T Contractor Address 680 Quinn Ave, San Jose, CA 95112 CA Lie# 485184 Class BC61/D40 HAZ <br /> A Insurer Insurance Company of the West Work Comp# WLV507821801 <br /> T ICC Technician's Name see attached Expiration Date <br /> o ICC Installer's Name Expiration Date <br /> R see attached P <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T _ r <br /> A <br /> N <br /> K <br /> las <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �_� C� \ _AA Date of 1 Z o (2 0 <br /> 11 <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 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 THWORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signaturee� ���••����✓" Title Permit and Project Coordinator Date 2/6/26 <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 Permit and Project Coordinator PHONE# 408-213-6039 <br /> ADDRESS 680 Quinn Ave,San Jose, CA 95112 <br /> r <br /> 17A <br /> '1 <br /> SIGNATURE DATE 2/6/26 <br /> 3 of 6 <br />