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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 />® TANK RETROFIT E PIPING REPAIRIRETROFIT B UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contac & Telephone # Marty Weithman 408-213-6038 <br />A <br />C <br />1 <br />Facility Name Safeway <br />Phone # 209472-8600 <br />L <br />Address 6425 N Pacific Ave Stockton CA 95207 <br />1T <br />CrossStreet Central Ct. <br />Y <br />Owner/Operator Safeway Inc. Phone # 925.467-2707 <br />C <br />Contractor Name Service Station Systems, Inc. Phone # 408-213-6038 <br />N <br />R <br />Contractor 680 Quinn Avenue CA Llc# 485184 Classg C61/D40 HAZ <br />A <br />DICC <br />Insurer ICW Group <br />Work Comp # yvpL502130700 <br />T <br />Technician's Name Justin Graves <br />Expiration Data 2/2812014 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />lis. 87 piping amp. 91 Ink ae*W. We 12, eocl <br />Tank Size <br />Chemicals Stored CUrtenll y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />8 Approved Approved with Conditions Ll Disapproved <br />L <br />A <br />(S Attachment With Conditions) <br />N <br />Plan Reviewers Nam,�z Date Z i 1r <br />APPLICANT MUST PERFORM ALL W RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAOUIN 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 W SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Appilunrs Signature ' -t-T-U V'}-{�L.U�91-.u.i-G"i--Tae Compliance Officer Data 12/10/2012 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. 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 dale below. <br />NAME Marty Weithman TITLE Compliance Officer PHONE # (408) 213-6038 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />V, <br />EH230038 (revised 0=0/09) <br />12/10/2012 <br />