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ENVIRONMENTAL HEALTH DEPARTMENZLwVil,:_-__ <br /> SAN JOAQUIN COUNTY JUL 2 9 2016 <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 /> ED TANK RETROFIT D PIPING REPAIRIRETROFIT UDC REPAIR/RETROFIT f] COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone 4 Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Gas Lo Phone# 209-957-2987 <br /> IAddress <br /> L 7906 N El Dorado <br /> I Cross Street Hammer Lane <br /> T <br /> Y Owner/Operator Paul Trahan Phone# 209-649-9838 <br /> Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> 0 <br /> N <br /> T Contractor Address 680 Quinn Avenue CA Lie# 485184 C18ssB,C61/D40, Htj <br /> R <br /> A Insurer Insurance Company of the West Work COMP# WPL 5021907 04 <br /> C <br /> T ICC Technician's Name Jerry Sanouvong Expiration Date 4/5/2018 <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> Re 87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ej Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date_,q 5- & <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUN410RDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: *1 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.' CONTRACTORS 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature _Me Compliance Officer D&Ie 7/27/2016 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EMD 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 /> j< <br /> SIGNATURE t7tT_-1 LL�&,.L DATE 7/27/2016 <br /> EH230038(revised 02/20/09) <br />