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} <br /> ENVIRONMENTAL HEALTH DEPA�RTWENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,Cai>jfornia-.95202 <br /> Telephone::(2'09)468-j420 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 REPAIRIRETR`OFIT B UDC REpAMRETROFIT EjC0Lb START1EVR I;lPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A Facility Name H&M Market Kwik SeryPhone# 209-838-3971 <br /> Address <br /> L 2501 Jackson Ave, Escalon CA 95320 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Boyette Petroleum Phone# 209-549-5612 <br /> a Contractor Name Able Maintenance Phone# 408-213-6038 <br /> T Contractor Address 3224 Regional Pkwy,Santa Rose CA 95403 CA Lie# 312844 ClaSSB.A,C10 <br /> RInsurer <br /> A State Camp Ins Fund Work Camp# 8073129 <br /> c ICC Technician's Name <br /> T Expiration Date <br /> a ICC Installer's Name Kelly Burningham Expiration Date: 1/20/2019 <br /> Tank system work area Rate UST <br /> (Le 87 pipinj-9 .V,91 look detector,UDC 112,ela) Tank Size Chemicals Stored:Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K E <br /> I . <br /> P Approved Approved with conditions T L HEAL FH <br /> L <br /> A (See Attachment With Conditions) DEPARTMENT <br /> N Plan Reviewers Name n ( Date 1 <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 AGENT'S 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 SECQME.SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUSCONTRACTIN13 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 70 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." `, vet,' <br /> ApPlicarneSignatunk �V. l ea Compliance OfficerDom 8/1/2018 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permft payment Coverage per-lank, 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 DATE 8/1/2018 <br /> 1EH230038(revised 0220109) <br /> 1 <br />