Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN <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 8 UDC REPAIR/RETROFIT ® COLD STARTIEVR 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 /> 1 Cross Street 1-205 <br /> T <br /> Y Owner/Op®rator RADC Enterprises Phone# 909-394-4728 <br /> C Contractor Name <br /> O Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 Clas <br /> R sg C61/D40 HAZ <br /> Insurer <br /> A Cypress Insurance Company Work Comp# 3310020636091 <br /> T ICC Technician's Name <br /> Matt Estabrook Expiration Dake 5/28/2011 <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currents Date UST <br /> (i.e87 pip <br /> . b�q sump,91 leak aelec�a,UDC in,ate.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ®Approved Approved with conditions 12 Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name__ <br /> 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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S MIRING 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> AppllcadsSlgnalure ( " "U4fqW, Compliance Officer Date 7/6/2011 <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 hj <br /> ito DATE 7/6/2011 <br /> EH230038(revised 02120/09) <br /> 1 <br />