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C <br />Ll <br />I . 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 />Q TANK RETROFIT ® PIPING REPAIRIRETROFIT ® UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <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 Stre at I-5 <br />Y <br />Owner/Operator Unocal 76 Phone 209-473-7337 <br />OC <br />-# <br />Contractor Name Service Station Systems, Inc. Phone # 408-213-6038 <br />TN <br />Contractor Address 680 Quinn Avenue <br />CA Lia# 485184 Cl8ssI3 C61/D40 HAZ <br />A <br />insurer Travelers Prop and Casualty <br />Work Comp # UB6054F2133 <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& 87 vi»ft soma, 91 selector, upc 112, etc.) <br />Tank Size Chemicals Stored Current � <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P® <br />Approved Approved with conditions Disapproved <br />L <br />A <br />(S achment With Conditions) <br />N <br />Pian Reviewers Nam Date <br />APPLICANT MUST PERFORM ALL ORK 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 <br />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 SBECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE "1 <br />FOLLOWING: 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 />AppncanrsStneture c -TIM Compliance Officer a., 3/30/2012 <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 />EH230038 <br />1 <br />3/30/2012 <br />