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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 780 DAYS FROM THE APPROVAL DATE_ INDICATE PERMIT TYPE BELOW; <br />TANK RETROFIT ® PIPING REPAIR/RETROFIT ® UDC REPAIRIRETROFIT EJ 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 Unocal <br />Phone # 209-473-7337 <br />I <br />L <br />Address 2701 W March Lane, Stockton CA 95219 <br />T <br />Cross Street 1-5 <br />Y <br />Owner/Operator Darren Eppler <br />Phone # 209-473-7337 <br />c <br />0 <br />Contractor Name Service Station Systems, Inc. <br />y <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lie# 485184 Classg C61040 HAZ <br />A <br />Insurer ICW Group <br />Work Comp # WPL502130700 <br />C <br />T <br />ICC Technician's Name Randy Wilkerson <br />Expiration Date 5/19/2013 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 Ink deteta, UDC 112, etc.) <br />Tank Size Chemicals Stored Currently <br />l7 <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved I ffApproved with conditions Disapproved <br />L <br />A <br />p: (See Attachment With Conditions) <br />N <br />Plan Reviewers Name , r'� Date _ �T/— <br />APPLICANT MUST PERFORM ALL WO 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 1N SUCH A MANNER AS TO SECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.` CONTRACTORS 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.' <br />ApplkanreSignature � ' t t T91e Compliance Officer Dem 6/12/12 <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 11A ,- �` DATE 6/12/2012 <br />EM230038 (revised 02/20/09) <br />1 <br />