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ENVIRONMENTAL HEALTH DEPARTMvENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton., California. 95202 <br /> Telephone : (2109) 468-3420 Fax * (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK REPAIR PERMIT <br /> THIS PERMIT EXPIRES 700 DAYS-FROM THE'APPROVAL wre. INDICATE PERMIT TYPE ' BELOW: <br /> 8 TANK RETROFIT 10 PIPING REPAIR7RETROFIT 8 UDC REPAIRIRETROFIT 8 COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Safeway #2600 Phone # 209-830-2950 <br /> I Address L Add1987 W 11th St, Tracy CA 95376 <br /> TCross Street <br /> Y Owner/Operator Corral Hallow PhorIle # 925467-2707 <br /> C Contractor Name Service Station Systems , Inc Rhone : 408-213-6038 <br /> N <br /> T Contractor Address 680 Quinn Ave , San Jose CA 95112 CA_Lic #. 485184 ClsssB C61ID40 <br /> R r <br /> Insuer <br /> A Insurance Company of the West Work:,Gomp # WPL 5021307 <br /> L ICC Technician's Name Expiration Date <br /> s,lc J .T p : <br /> p ICC Installer's Name Expiration Date <br /> Tank system work area Date PSTtn <br /> (i.e 67 piping sump; 81 leakdetedor, UDC Wt dtc.) Tank Size Chemicals Stored Currently <br /> installed <br /> T <br /> A <br /> N <br /> K k 11 <br /> � . <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N 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: `1 GVATIFYTHAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1. 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`WORKEgt COMPENSATION LAWS. <br /> OF CALIFORNIA:` <br /> `� � , ,, .E-, / Compliance Officer 6/21 /2019 <br /> Appllcanl'sSlgneture Y�IIK.�-`tom ' �' TtBu Data. i <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.9 , property owner, the party must acknoWledge this <br /> responsibility for the bllling by signature and datebelow, <br /> NAME Marty Weithman TITLE Compliance Officer PHONE # 408-213-6038 <br /> ADDRESS 68,0 �Quinn Ave . San Jose , 9}5�1�1 ,2 <br /> SIGNATURE <br /> / til ct.lsi t�4 t V . �� " "�'�u -d-�'V DATE 6/21 /2019 <br /> EH230038 (revised 02/20109) <br /> 1 <br />