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• A •� - :, - <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 ® PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br />A F <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name AT&T UG010 <br />Phone# 559--222-2313 <br />1 <br />L <br />Address 1812 Colev Ave, Escalon CA 95320 <br />TCross <br />Street <br />Y <br />Owner/Operator AT&T California <br />Phone # 214-464-5591 <br />C <br />0 <br />Contractor Name Able Maintenance Inc. <br />Phons 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 312844 ClaSSB, A, C10 HAZ <br />R <br />A <br />Insurer 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 />o <br />R <br />ICC Installer's Name <br />'Expiration Date <br />Tank system work area <br />Ii:e. 87 piping sump, 91 leak detector, UDC W, ate.) <br />Tank Size Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />Plan Reviewers Name 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 AGENT'S 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 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 $HALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicants Si nature 11-ie Compliance Officer Date 4/7/2014 <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 />I <br />EH230038 (revised 02120/09) <br />4/7/2014 <br />