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ENVIRONMENTAL <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 /> 10 TANK RETROFIT ® PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT ® COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Tracy Blvd Shell and Mini Mart Phone# 209-835-7608 <br /> I Address y <br /> L 3725 N Trac Blvd,Trac CA 95376 <br /> I Cross Street 1-205 <br /> T <br /> Y Owner/Operator RADC Enterprises Phone# 909-394-4728 <br /> Contractor Name <br /> oc Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 Class <br /> Insurer p y B C61/D40 HAZ <br /> AR Travelers Pro and Casualty Work Comp# UB6054F2133 <br /> T ICC Technician's Name Randy Wilkerson Expiration Date 5/19/2013 <br /> R IGC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Dale UST <br /> (i.e.87 piping sump,91 k detactpr,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> Kra ' <br /> P ®Approved <br /> L Approved With conditions (� Disapproved <br /> A (S Attachment.With Conditions) <br /> N Plan Reviewers Name <br /> AA <br /> Date 10 <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 1S 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: '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 /> Applicanrs Signalte P z� Tae Compliance Officer ®ata 4/2/2012 <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 711 C �, J ° On i, GATE 4/2/2012 <br /> EM230038(revised 02/20109) <br /> 1 <br />