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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 APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT E PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Food 4 Less Phone# 209-234-7869 <br /> 1 Address <br /> L 3408 Manthey Rd. Stockton CA 95206 <br /> TCross Street <br /> Y Owner/Operator Food 4 Less/Robert Silva Phone# <br /> 209-858-0101 <br /> o Contractor Name Service Station Systems, Inc. Phone# <br /> 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Classg C61040 HAZ <br /> R Insurer p <br /> A ICW Group Work Comp# WPL502130700 <br /> DICC Technician's Name <br /> T Michael Briggs Expiration Date 7/12/2013 <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e 87 piping sump,91 leak detector,UDC 1R,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions 12 Disapproved <br /> A <br /> A (See Attachment With Conditions) <br /> � <br /> N Plan Reviewers Name Date 1� f <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 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicant'sSignatureL � L �t�'�T+ae Compliance Officer Date 2/19/2013 <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, <br /> 95112, <br /> SIGNATURE !1(4t i i l /U� (/LL�,I�-4 ' DATE 2/19/2013 <br /> EH230038(revised 02/20/09) <br /> 1 <br />