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U <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 />TANK RETROFIT 10 PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT 8 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 Valero Phone # 209-825-4569 <br />I <br />L <br />Address 1001 E Yosemite Ave, Manteca CA 95336 <br />I <br />T <br />Cross Street Ra lowe Ave <br />Y <br />Owner/Operator Miariana <br />Phone # 209-825-4569 <br />oContractor <br />Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CAI lc # 485184 ClassB C61/D40 HAZ <br />A <br />Insurer ICW <br />Work Comp # WPL502130702 <br />T <br />ICC Technician's Name Kris Bell <br />Expiration Date 10/2/2014 <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(Le 87 piping sump, 91 leak detector, UDC 1R, etc.) <br />Tank Size Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved X.Approved with conditions ID Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />�� <br />Plan Reviewers Name�� l� o� 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: "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." j►,� f <br />� b � Compliance Officer <br />Applicants Signature -Lt ,z t trlde pate 6/16/2014 <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{, 95,112( <br />SIGNATURE PA—LLLw " 1 ~`r` DATE 4/30/20146/16/2014 <br />EH230038 (revised 02/20/09) <br />