Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPART WE1VE1, <br /> SAN JOAQUIN COUNTY JUL 0 2 2015 <br /> 600 East Main Street, Stockton, California 95202 A!.ONMEN <br /> RVIT <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 F�NIT <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 REPAIRIRETROFIT 8+ UDC REPAIR/RETROFIT X COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> G Facility Name Rancho San Miguel Market(Food for Less) Phone# 209-942-2840 <br /> I Address <br /> L 1409 S.Airport Way, Stockton CA 95206 <br /> 1 Cross Street <br /> T Charter <br /> Y Owner/Operator UesUS �Jw(I_6LCT Phone# 209-992-7620 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> o Y 408-213-6038 <br /> N Contractor Address <br /> T 660 Quinn Avenue CA LID# 312844 ClassB,C61040, Hell <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 502190702 <br /> DICC Technicians Name <br /> T ' M ke Briggs Expiration Date (µ 17 <br /> oICC Installer's Name <br /> R Expiration Dale <br /> Tank system work area Tank Size Chemicals Stored Currenll Date UST <br /> (.e 8rPiplnp,amp,91look det.W.UDC In,el[J y Installed <br /> T <br /> A <br /> K <br /> PAApproved with conditions Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> 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: '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 <br /> TO 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> j <br /> Appliunrs Signarore(I. rC(- -C.L`t{t.t u..(e,1 -Tore Compliance Officer Date 7 i v2.Cgs <br /> BILLING INFORMATION: <br /> Indicate (he responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. 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 Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose, 95112 <br /> SIGNATUREi J t ,j,-T- I IL(.�I i.l_ It It, 1 DATE <br /> EH230038(revised 0220/09) <br /> 1 <br />