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v <br />J <br />ENVIRONMENTAL HEALTH DEPART4EIVEL <br />SAN JOAQUIN COUNTY JUL 0 2 2015 <br />600 East Main Street, Stockton, California 95202 17 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 NVIRONMENTAL <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 E PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />O <br />Facility Name Rancho San Miguel <br />Phone # 209-339-8200 <br />I <br />L <br />Address 610 S Cherokee Lane, Lodi <br />TCross <br />Street <br />Y <br />Owner/Operator Jesus Jurado <br />Phone # 209-992-1463 <br />Q <br />o <br />Contractor Name Service Station Systems, Inc. <br />Y <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic # 312844 ClassB, C61 ID40, Hlh <br />R <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WPL 502190702 <br />D <br />T <br />ICC Technician's Name M ke Briggs <br />Expiration Date g/11/17 <br />Q <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />v a 87 plying sump. 91 took detector, Uoc la, etc.) <br />Tank Size <br />Chemicals Stored Currentl Y <br />Dale UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />®Approved conditions ElDisapproved <br />L <br />A <br />%povedwith <br />(Sith Conditions) <br />-7-7-//S` <br />N <br />Plan Reviewers Name Dale <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 AGENTS 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 <br />TO WORKERS 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />UL« <br />Applicants slgnat cc-'t� Compliance Officer _ De,e 7/1/2015 <br />BILLING INFORMATION: <br />Indicate the responsible parry 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 Weilhman TITLE Compliance Officer PHONE # (408) 213-6038 <br />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE VI [1C�t.L lr�-L-I�A.Jf'<<+-��I� DATE 7/1/2015 <br />EH230038 (revised 02/20/09) <br />