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ENVIRONMENTAL HEALTH DEPARTMENT -232015 <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />.... ,ANMENTA[ . <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 />ED TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Marty We thman 408-213-6038 <br />A <br />Q <br />Facility Name Safeway #2707 <br />Phone # 209-472-8600 <br />IAddress <br />L <br />6425 N Pacific Ave, Stockton CA 95207 <br />I <br />T <br />Cross Street Central Ct. <br />Y <br />Owner/Operator Misty Cook <br />Phone # 209-472-8600 <br />o <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 312844 ClassB, C61/D40, Hb <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WPL 502190702 <br />T <br />ICC Technician's Name Randy Wilkerson <br />Expiration Date 5/2/15 <br />qICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(Le. 87 piping Earp, 91 leak deteptw, UDC W, eta) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved tWApproved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />/J� / L '1 <br />Plan Reviewers Name NLG1N 2 /�LpA�1 Qom_ Date `1 — O � --1 <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 WORKERS 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 />c ��I' Ivr�" +-(,L,4 tr ff. Compliance Officer 4/21/2015 <br />Applkanrs Slgneturaft Dai <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 />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE !1 aaALA� Li DATE 4/21/2015 <br />EH230038 (revised 02/20/09) <br />