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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 El PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name Safeway Phone# 209-472-8600 <br />I <br />L <br />Address 6425 N Pacific Ave Stockton CA 95207 <br />T <br />Cross Street Central Ct <br />Y <br />Owner/Operator Safeway <br />Phone # 925-467-2707 <br />o <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />485184 Class <br />CA Lic# B C61/D40 HAZ <br />RA <br />Insurer ICW Group <br />Work Comp# WpL502130700 <br />DICC <br />T <br />Technician's Name Lee Williams <br />Expiration Date <br />QICC <br />5/19/2013 <br />R <br />Installer's Name <br />Expiration Date <br />Tank system Work area <br />lie 87 plpl�g eanp, 81 Wk detector, UDC M. etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />� <br />A <br />N <br />K <br />P <br />Approved , Approved with conditions Disapproved <br />L <br />A <br />(S�e A h ant With Conditions) <br />N <br />Plan Reviewers Name "114 Date 16 2IZ <br />v <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.' 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 WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />-117 <br />1 <br />APPIIcenCe Slgn,lere),, (.Uci L-4� 1y,('YC f,1, L11-411.rIM Compliance Officer Det, 9/11/2012 <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 68,/0 Quinn Ave. San Jose(,, 951122 <br />SIGNATURE It (1/1, 1/1,d -Lt— 1b �L.Lc�1.J�� DATE 9/11/2012 <br />EH230038 (revised 02,20/09) <br />