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ENVIRONMENTAL HEALTH DEPARTM-ENT <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 D UDC REPAIR/RETROFIT a COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Valero 3641 Phone# 209-477-3111 <br /> 1Address <br /> L 1210 E Hammer Lane, Stockton CA 95210 <br /> TCross Street <br /> Y Owner/Operator Valero Energy Phone# 209-477-3111 <br /> C Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 Classg C61040 HAZ <br /> A Insurer ICW Work Comp# <br /> WPL502130701 <br /> C ICC Technician's Name <br /> T Jarrett Flewellyn Expiration Date 4/23/2015 <br /> QICC Installer's Name R NExpiration Date <br /> Tank system work area Tank gine Chemicals Stored Current Date UST <br /> (is.87 piping sump,91 teak detwor,UDC 1n,etc.' Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approved pproved with conditions 0 Disapproved <br /> L ? (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Namtz°'.J H Date <br /> <' <br /> APPLICANT MUST PERFORM ALIORK 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 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO'BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,'SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> iconrsSignature �'��t7 ® Compliance OfficerDate 9/3/2013 <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 /> SIGNATURE ';I t-,L l DATE 9/3/2013 <br /> EH230038(revised 02120109) <br /> 1 <br />