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n <br />Ll <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 Ia PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />G <br />Facility Name AT&T <br />Phone 310-308-9954 <br />I <br />L <br />Address 1812 Cole Ave Escalon CA 95320 <br />I <br />T <br />Cross Street 2nd <br />Y <br />Owner/Operator Pacific Bell Telephone dba AT&T California <br />Phone # 214-464-5591 <br />C <br />D <br />Contractor Name Able Maintenance, Inc. <br />Phone # 707-545-5522 <br />N <br />T <br />Contractor Address 3224 Regional Parkway, Santa Rosa 95403 <br />CA Lic# 312844 Class B A C10 HAZ <br />RA <br />Insurer Insurance Company of the West <br />Work Comp # WPL500060304 <br />T <br />ICC Technician's Name <br />Expiration Date <br />a <br />ICC Installer's Name Mark Tillotson <br />Expiration Date 7/19/2013 <br />Tank system work area Tank Size Chemicals Stored Current Date UST <br />(Le ea ,wnp.91 EeWW, UDC VY, etc.) IY <br />Installed <br />T <br />A <br />N <br />IN <br />K <br />P <br />pproved with conditions Disapproved <br />Approved XAttach <br />1 <br />A <br />(S m nt With Conditions) <br />N <br />Pian 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 9 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 WORKERS COMPENSATION LAWS OF CALIFORNIA.` CONTRACTOR'S HIRING OR SUBCONTRACTING 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 TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />} <br />Appllwnrsslgnaiwe L t��'� �� i -L Compliance Officer 3/5/2013 <br />Dem <br />I*I14Ik, Lei li!1kol <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 P (408) 213-6038 HONE 1€_ <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE ` � a t - t�DATE 3/5/2013 <br />EH230038 (revised 02./20109) <br />1 <br />