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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 /> 8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Rancho San Miguel Market Phone # 209-942-2840 <br /> I Address L Add1427 S Airport Way , <br /> Cross Street Charter Way <br /> T <br /> Y Owner/Operator Food 4 Less Phone # 209 -858-0101 <br /> c Contractor Name Able Maintenance , Inc Phone # <br /> Q 408-213 6038 <br /> Contractor Address <br /> TN 680 Quinn Ave , San Jose CA 95112 CA Lic # 312844 Classg , A , C10 HAZ <br /> R Insurer <br /> A State Comp Ins Fund Work Comp # 9023719 <br /> T ICC Technician 's Name Expiration Date <br /> QICC Installer's Name <br /> R Kelly Burningham Expiration Date 1 /6/2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump, 91 leak detecto(, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved & Approved with conditions 12 Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name a-k \ � � Date NEI <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 : 01 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 /> Applicants Signature "'l3S — L� y r� ��(.� Tme Compliance Officer Date 9/ 10/2019 <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 . Stan `A )Joose ,, 951QC 4�e12 <br /> SIGNATURE ��� U, 4 ,tW&; DATE 9/ 10/2019 <br /> EH230038 (revised 02/20/09) <br /> 1 <br />