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r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 ® PIPING REPAIRIRETROFIT ® UDC REPAIRIRETROFIT [I COLD STARTIEVR UPGRADE <br /> F I EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Rancho San Mi uel Market Phone# 209-942-2840 <br /> Address I <br /> L S.Airport Way <br /> I Cross Street Charter Way <br /> T <br /> Y Owner/Operator Gilbert Silva Phone# 209-942-2840 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> a y 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 312844 Classg, C61/D40, H$ <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 502190702 <br /> T ICC Technician's Name Joseph Hardy Expiration Date 2/2012016 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date IST <br /> (i a 87 piping sump,91 leak deleaor,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K � <br /> P Approve pproved with conditionsL] Disapproved <br /> L (S A nt it Conditions) <br /> A 71 N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUN ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JDAOUIN 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 7)iIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WCRKER'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.' <br /> Applicanrssignetvm ` �`� C-�- :/ -t C�4__LL4f. �}g, Compliance Officer Det, 7/14/2014 <br /> BILLING INFORMATION; <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permh 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 PH©NE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. San 4Jose, 95112 <br /> SIGNATURE�1 {.{CX—CT7f t� \; � ���1<{�vLC�C�i•� DATE 7/14/2014 <br /> EH230038(revised 02120109) <br /> 1 <br />