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ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephones (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 REPAIR/RETROFIT ® UDC REPAIR/RETROFIT Ej COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Shell Phone# 209-835-7608 <br /> 1 Address y <br /> L 3725 N Trac Blvd,Trac <br /> I <br /> T Cross Street 1-205 <br /> Y Owner/Operator RADC Enterprises Phone# 909-394-4728 <br /> R Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 ClassB C61/D40 HAZ <br /> R A Insurer Cypress Insurance Company <br /> Work Comp# 331002063601 <br /> T ICC Technician's Name Genaro Martinez Expiration Date 4/26/2013 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently pale UST <br /> (i.e.e7 alc�+a swnp,91 Ink deleM,UDC 1n,eks <br /> T <br /> A <br /> N <br /> K <br /> P ®Approved Approved with conditions 0 Disapproved <br /> L (See Attachment With Conditions) <br /> A ::�" 1-1\ <br /> N 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 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 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.' <br /> ApplIce nrsSlgmture ,. : ' Compliance Officer Dale 9/12/11 <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 IiA:t�L 9/12/11 <br /> aATE <br /> EM230038(revised 02/20/09) <br /> 1 <br />