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i <br /> i <br /> ENVIRONMENTAL HEALTH D :=-PARTMEAT � � <br /> SAN JOAQUIN COUNTY SEP � n 2019 <br /> 600 East Main Street, Stockton , California 9520.2 <br /> Telephone: (209) 468-3420 Fax : (209) 468-3433 ENVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING . FffA? t iFtWhffj <br /> THIS PERMIT EXPIRES 18D' OAYS FROM THE APPROVAL DATE. INDIOATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT PIPING REPAIR/RETROFIT t3 UDC REPAIR/RETROFIT 8 COLD JuRvEvIl UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> 0 Facility Name H & M Market Kwik Serv) Phone ,# 209-838 -3971 <br /> I ress <br /> L Add2501 Jackson Ave , Escalon CA 95320 <br /> 7 Cross Street <br /> Y Owner/Operator Boyette Petroleum EEEEPhone # 209 -549-5612 <br /> o Contractor Name Able Maintenance Phone #. 408-213 -6038 <br /> N Contractor Address 3224 Regional Pkwy, Santa Rose CA 95403 CA Lic # 312844 Class13 .A, C10 <br /> A Insurer State Comp Ins Fund Work Comp # 9073129 <br /> c <br /> T ICC Technician's Name 8x i <br /> ration Dale <br /> Q <br /> P 1 <br /> R ICC Installer's Name Kelly Burningham Ezpication bate- t 121 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> Ii:e 87plpfngsump, 01leakdetector, UDC121etcj y <br /> (nsialled <br /> T <br /> A <br /> N <br /> K <br /> P provea, Approved with conditions 0 Dlsbpproved <br /> :j <br /> L ( echment With Conditions ) <br /> A 11 <br /> N Plan Reviewers Name hate V 12C� ) C/I <br /> r <br /> APPLICANT MUST PERFORM ALL WO IN Q� CORD E.WITH SAN JOAQUIN COUNTY ORDINANCES # STATE LAWS, AND RULES AND REGULATIONS, OF :SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL I TH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES. THE FOLLOWING% 'I CERTIFY'THAi 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 B9cOME SUB&& <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TME. FOLLOWING: "LCEATIFY <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 /> Applicants Signaturel�tS- -�-� Y . yB Compliance Officer Dote <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 tpermil applicant, e.g. property owner., the party must acknowledge this <br /> responsibility for the billing by signature and date below, <br /> NAME Marty Welthman TITLE Compliance Officer PHONE # 408-213-6038 <br /> ADDRESS '6j8^0 /Quinn Ave. San Jose , 96112 n <br /> SIGNATURE i K;0i�trL 4 �. i .{ � �yt�. DATEI/ 4 <br /> �y <br /> EH230038 (revised 02120/09) <br /> 1 <br />