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ENVIRONMENTAL HEALTH DEPA-RTM- <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 .SUN 0 2 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR,PERM1COAUITAChIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT 10 PIPING REPAIR/RETROFIT El UDC REPAIR/RETROFIT a COLI? STARTIEVR UPGRADE <br /> F EPA Site# Project <br /> A Contact&Telephone#Marty Weithman 408-213-6038 <br /> c Facility Name Rancho San Miguel Market (Food for Less) Phone# <br /> Address 209-942-2840 <br /> L 1409 S.Air ort Wa , Stockton CA 95206 <br /> TCross Street Charter <br /> Y Owner/Operator Gilbert Silva Phone# <br /> C Contractor Name y 20g-992-7620 <br /> o Service Station Systems, Inc. Phone# <br /> N 408-213-603$ <br /> T <br /> R Contractor Address 680 Quinn Avenue CA Lic# 312844 Clsssg C611/D40, Hlb <br /> Insurer <br /> A Insurance Company of the West <br /> c Work Comp# WPL 502190702 <br /> ICC Technician's Name <br /> RT M ke Briggs Expiration Date 7/1/2015 <br /> ICC installer's Name <br /> Expiration Date <br /> 'bank system work area <br /> (i.eB7 pipTank Size Chemicals Stored Currently Date UST <br /> . piping sump,91 leak defector,UDC 1/2,elc.J <br /> Installed <br /> T <br /> A <br /> N <br /> K '• <br /> P Approved Approved with conditions I� Disapproved <br /> pproved <br /> A (See chment With Conditions) <br /> N Plan Reviewers Name <br /> Date— <a <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 <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 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' f r <br /> Applicants Signature! �4 C { t t . t�f.i z i 1u� Compliance Officer DaI, 5/29/2015 <br /> BILLING INFORMATION; <br /> Indicate the responsible party 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 Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose, 95112 <br /> SIGNATURE DATE 25/29/2015 <br /> EH230038(revised 02120/09) <br />