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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 APPR OVAL DATE INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ® COLD START,EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# Charles York (831)227-4729 <br /> A <br /> C Facility Name Valero Service Station Phone# (209)832-8815 <br /> � Address 153 East Eleventh Street,Tracy,CA <br /> 1 Cross Street F Street <br /> T <br /> Y Owner/Operator Valero Califomia Retail Co. Phone# (559)583-3231 <br /> 0Contractor Name Triton Construction Phone# <br /> 0 it (831)227.4729 <br /> T Contractor Address 2560 Soquel Avenue#202 CA Lie# 693807 Class A-B-HAZ <br /> AInsurer Delos Insurance Company Work Comp# 01 DKRM12006615 <br /> C ICC Technician's Name Anthony <br /> T Y Spielman <br /> Expiration Date May 21,2010 <br /> R ICC Installer's Name Anthony Spielman Expiration Date May 22,2010 <br /> Tank system work area Tank Size Chemicals Stored Current Date UST <br /> (i.e.87 PON sump,91 leak detects,UDC 1Q.eaJ y Installed <br /> T 10,000 gallon Unleaded <br /> A 10,000 gallon Unleaded <br /> N <br /> K 10,000 gallon Premium <br /> P ❑ App ved4 pproved with conditions Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name t <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AN D RULES AND REGULATIONS OFSAN <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 15 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: 1 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 /> Applicant's Signature @— Title ghWpjrP-Acor-AT Dam 8//A-/O <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD at aff 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 Charles York TITLE Owner Agent PHONE# (831)227-4729 <br /> ADDRESS 2560 Sequel Avenue#202 / / <br /> SIGNATURE �� DATE .6 /'2 A <br /> EH230038(revised 02/20/09) <br /> 1 <br />