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• . 1 a c . <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 ® PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Valero #3641 Phone # 209-477-3111 <br />1 <br />L <br />Address 1210 E Hammer Lane Stockton CA 95210 <br />TCross <br />Street <br />Y <br />Owner/Operator Valero Energy Corporation <br />Phone# 209-477-3111 <br />C <br />o <br />Contractor Name y <br />Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WPL502130700 <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i* ea pi> 9�, 91 Ink deftlw, UDC 1)2, etc.) <br />Tank <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 />A <br />- See Attachment With Conditions) <br />N <br />_r <br />Pian Reviewers NamB- Date 0 d <br />2 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAGUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 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 <br />SECOME 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />f <br />AppllcenraSl nstwe - -� 1 A L1;t# Compliance Officer Det, 6/29/2012 <br />BILLING INFORMATION: <br />Indicate the responsible parry 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 /># <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />EM230038 (revised 02/20/09) <br />MJ <br />6/29/2012 <br />