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E <br />Ll <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 458-3420 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 10 PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT a COED START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name Unocal 76 <br />Phone # 209-473-7337 <br />1 <br />L <br />Address 2701 March Lane, Stockton CA 95219 <br />I <br />T <br />Cross Street 1-5 <br />Y <br />Owner/Operator Darren Eppler <br />Phone # 209-473-7337 <br />c <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />NContractor <br />T <br />Address 680 Quinn Avenue <br />CA Lic # 485184 Classg C61/D40 HAZ <br />RInsurer <br />A <br />ICW Group <br />Work Comp # WPL502130700 <br />cICC <br />T <br />Technician's Name Matt Estabrook <br />Expiration Data 5/19/2013 <br />oICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i,e. 87 piping sump, gt leak detector, UDC W, etc.) <br />Tank Size <br />Chemicals Stored Correnti y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved- pproved With conditions ID Disapproved <br />L <br />A <br />ee Attachment With Conditions) <br />N <br />Pian Reviewers Name i" Date f_ 7 <br />APPLICANT MUST PERFORM ALL QRK 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 WORKERS 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 />' <br />Applicants Signature ' �� a �xN® Compliance Officer Date 11/26/2012 <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 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE,-`: �L't " <br />EH230038 (revised 02/20/09) <br />1 <br />11/26/2012 <br />