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0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 /> 8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT a UDC REPAIR/RETROFIT a COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Shell Phone# 209-836-8908 <br /> 1Address <br /> L 2375 W Grant Line <br /> I Crass Street 1-205 <br /> T <br /> Y Owner/Operator Shell Oil Products Phone# 310-816-2207 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> R Insurer <br /> A Cypress Insurance Company Work Comp# 3310020636091 <br /> GICC Technician's Name <br /> T Randy Wilkerson Expiration Date 10/23/2011 <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1Q,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P EJ Approved pproved With conditions b Disapproved <br /> L IS chment With Conditions) <br /> A <br /> N Pian Reviewers Nam <br /> - Date GC) <br /> APPLICANT MUST PERFORM ALL WORK IN RDANGE 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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO VECOME 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,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicanrs SignatureL-L4 Compliance Officer Date 5/25/2010 <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 /> ADDRESS 680 Quinn Ave. San Josses,95112 <br /> SIGNATURE„{ lLt .:w /'�-t �, DATE 5/25/2010 <br /> EH230038(revised 02/20/09) <br /> 1 <br />