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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 /> TANK RETROFIT PIPING REPAIR/RETROFIT C1 UDC REPAIR/ RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Kwik Sery Lodi Phone # 209 -369-2790 <br /> I Address L Add420 W Kettleman Lane , Lodi CA 95240 <br /> Cross Street West Lane <br /> T <br /> Y Owner/Operator Boyette Petroleum Phone # 209 -549-5612 <br /> C Contractor Name Able Maintenance , Inc Phone # <br /> D 408 -213-6038 <br /> TN Contractor Address 680 Quinn Ave , San Jose CA 95112 CA Lic # 312844 ClassB ,A , C10 HAZ <br /> R Insurer <br /> A State Comp Ins Fund Work Comp # 8023719 <br /> T ICC Technician 's Name Expiration Date <br /> DICC Installer's Name <br /> R Kelly Burningham Expiration Date 1 /6/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Dale UST <br /> (i.e 87 piping sump, 91 leak detects, UDC 1/2, etcJ Installed <br /> T ( <br /> IN aS <br /> Y <br /> K <br /> P FZJ Approved Approved with conditions M Disapproved <br /> L e ttachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE 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 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' � � <br /> Applicant's Signature " tt�j'u' U ' 'It ttLay.,71fle Compliance Officer Date 10/9/2019 <br /> BILLING INFORMATION : <br /> j Indicate the responsible party to be billed for additional EHD staff lime 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 14A21. �� i1,�1 Nt'� DATE 10/9/2019 <br /> EH230038 (revised 02/20/09) <br /> 1 <br /> I <br />