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ENVIRONMENTAL HEALTH EPARTY,§QL,.�,. - <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 JUN 2 4 2016 <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 D PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Waterloo Shell#136143 Phone# <br /> 209-931-3674 <br /> Address <br /> L 4315 E Waterloo Rd, Stockton CA 95215 <br /> I Cross Street Hwy gg <br /> T <br /> Y Owner/Operator Dealer(MAyra Rupi) Phone# 209-931-3674 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> o Y 408-213-6038 <br /> T CA Lic# 312844 Class Contractor Address 680 Quinn Avenue <br /> B, C61/D40, Hil <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL 502190702 <br /> C ICC Technician's Name <br /> T Peter Thibault Expiration Date 12/22/2017 <br /> o ICC Installer's Name <br /> R Expiration Date <br /> Tanksystem work area Tank Size Chemicals Stored Current/ Date UST <br /> lie 87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Fj Approved pproved with conditions 0 Disapproved <br /> L (Sde Attachment With Conditions) <br /> A �- <br /> N Plan Reviewers Name r } k� ��1�'� i� Date <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 AGENT'S 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 /> Applicants Signature rct T1uo Compliance Officer Dale 6/21/2016 <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, 9�511�2 <br /> SIGNATURE I1.( Cl t � -L'A., " .(� � �w�L�� DATE 6/21/2016 <br /> EH230038(revised 02/20/09) <br /> 1 <br />