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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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />8 TANK RETROFIT ® PIPING REPAIR/RETROFIT ® UDCREPAIRIRETROFIT ® 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 Valero Phone # 209-825-4569 <br />1 <br />L <br />Address 1001 E Yosemite Ave, Manteca CA 95336 <br />T <br />Cross Street Ra lowe Ave <br />Y <br />Owner/Operator Miariana <br />Phone # 209-825-4569 <br />cContractor <br />o <br />Name y <br />Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lie# 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 />oICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 plpinpawnp, 91 leak detector, UDC V2, etc:) <br />Tank Size Chemicals Stored Correnti y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved H Approved with conditions 0 Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 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; 1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 <br />M <br />Applicants Signature -- 11 ° b` c �v—ccyjae Compliance Officer Dei 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, 95112 <br />SIGNATURE..N <br />EH230038 (revised 02/20109) <br />1 <br />4/30/20146/16/2014 <br />