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MECEIVED <br /> ENVIRONMENTAL HEALTH D .EPARTMEPNT2020 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> 600 East Main Street, Stockton , California 95202 PERMIT/ SERVICES <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 Ia PIPING REPAIR/RETROFIT 8 UDC REPAIR/ RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Speedway Phone # 209-368-8787 <br /> I Address L Add401 W Kettleman Lane , Lodi CA 95240 <br /> Cross Street Hutchins <br /> T <br /> Y Owner/Operator Speedway Phone # 253-896-8809 <br /> C Contractor Name Service Station Systems , Inc Phone # 408-213-6038 <br /> T Contractor Address 680 Quinn Ave , San Jose CA 95112 CA Lie # 485184 ClassB , C61 /D40 H <br /> R Insurer <br /> A Insurance Company of the West Work Comp # WPL 5021307 <br /> T ICC Technician 's Name Brian McPheeley Expiration Date 11 / 1 /2021 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump, 91 leak detector, UDC in, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions 15 Disapproved <br /> L ( e A hment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDAN 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 : "1 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." d <br /> Applicants Signature r'��l; Lf I Qltle Compliance Officer Date <br /> 2/ 14/2020 <br /> BILLING INFORMATION , <br /> Indicate the responsible party to be billed for additional EMD 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 6880 Quinn Ave . San Jose , 95112 <br /> SIGNATURE 11. (,� �I Ll DATE 9/ 10/2019 <br /> EH230038 ( revised 02/20/09) <br /> 1 <br />