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.. !willy . <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 />TANK RETROFIT 10 PIPING REPAIRIRETROFIT ® UDC REPAIR/RETROFIT ® COLD STARTlEVR UPGRADE <br />F <br />1 EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <br />c <br />Facility Name AT&T UGO10 <br />Phone # 559-222-2313 <br />1 <br />L <br />Address 1812 Coley Ave, Escalon CA 95320 <br />TCross <br />Street <br />Y <br />Owner/Operator AT&T California <br />Phone# 214-464-5591 <br />CContractor <br />Name Able Maintenance Inc. <br />Phone# 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 312844 Glass B, A, C10 HAZ <br />RInsurer <br />A <br />State Compensation Insurance Fund <br />Work Comp # 9073219-13 <br />T <br />ICC Technician's Name Sam Sousa <br />Expiration Date 9/10/2015 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC W, etc.) <br />Tank Size <br />Chemicals Stored Current) Date UST <br />y Installed <br />T <br />A <br />N <br />K <br />P <br />Approved pproved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />i <br />Plan Reviewers Name. ®` MaAAA10 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: '1 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: 'I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, l SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />�`_t <br />ApplicanrsSignstUre c.t_ , - ��� i �� rs a fie Compliance Officer Dsle 4/7/2014 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EMD 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 />DATE <br />SIGNATURE �4/7/2014 <br />` C} L �9 I-�, . ,�_ l d � moi: <br />EH230038 (revised 02/20109) <br />1 <br />