Laserfiche WebLink
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 U PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />EPA Site # <br />Facility Name Safeway #2707 <br />Address 6425 N Pacific Ave Stockton CA 95207 <br />Cross Street Central Ct. <br />Owner/Operator Safeway Inc. <br />Contact 6 Telephone # Marty Weithman <br />_ Phone# .2na-e <br />Contractor Name Able Maintenance, Inc. <br />Contrac(or AddresS 3224 Regional Parkway, Santa Rosa 95403 <br />Insurer State Compensation Insurance <br />ICC Technician's Name Mike Trejo <br />ICC Installer's Name <br />Tank system work area <br />(i a e) pipldg a.p. 91 Idak detector. enc In. etc.) <br />Plan Reviewers <br />d Approved <br />Tank Size <br />Phone # 925-467-2707 <br />Phone # 408-213-6038 <br />CA Lic # 312844 Class B A C10 HAZ <br />Work Comp # 9073219-14 <br />Expiration Dale 4/12/2015 <br />Expiration Date <br />Chemicals Stored Currently Dale UST <br />Installed <br />8 Approved with conditions Disapproved <br />(See Attachment With Conditions) <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' -T <br />Appilcanrs Signalvre(((rrtfi rc I_. /�_( C 4 C"L-{r Title Compliance OfficerOates 2/24/2015 <br />Indicate the responsible party to be billed for additional EHD staff lime 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 />Quinn Ave. San Jose. 95112 <br />SIGNATURE (_r,.L-t4. <br />EH230038 (revised 02/20/09) <br />2/24/2015 <br />