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s <br /> i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone : (2 09) 46.8-3420 Fax : (209) 468.3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT`OR :PIPING. REPAIR. PERMIT <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE eELOW% <br /> ��. TANK RETROFIT Ia PIPING REPAIR/RETROFIT 13 UDC REPAIRIRETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> G Facility Name Safeway #2600 Phone # 209-830-2950 <br /> I Address <br /> L 1987 W 11th St, Tracy CA 95376 <br /> T <br /> Cross Street Corral Hallow <br /> Y Owner/Operator Safeway Phonic # 925467-2707 <br /> C Contractor Name Service Station Systems , Inc Phone 408-213-6038 <br /> 0 <br /> T Contractor Address 680 Quinn Ave , San Jose CA 95112 CA Lio.# 485184 CiassB C61 /D40 <br /> A Insurer Insurance Company of the West Work. Comp # WPL 5021307 <br /> C <br /> T ICC Technician's Name- tNolration Date <br /> o <br /> R ICC Ihstaller's - Name Expiration Data <br /> Tank;system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump, 6 leak detector, UDC 112l etas Installed <br /> i <br /> i <br /> I T <br /> A <br /> i N <br /> s <br /> K <br /> P Approved ,AWith Approved with conditions Disapproved <br /> (Se? Attachment <br /> L Conditions) <br /> A <br /> N Plan Reviewers NameDate. <br />' APPLICANT MUST PERFORM ALL WORK IN ACCORDANCEWITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES: AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTM NT. OWNER OR LICENSED AGENT S SLGNA7IJRE '6ERiJFIE3. THE FOLLOWING: "t CERTiFY'7HAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS .PERMIT Is ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUd1H A MANNERAS TO.BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA,* CONTRACTOR'S HIRING. OR SUBCONTRACTING SIGNATURE CERTIFIES THE ;FOLL.6WJNG `tLERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR-WHICH THIS'PERMIT IS ISSUED, I SHALL.EMPLOY PERSONS`SUBJECT TO 'WORKER'S COMPENSATtbN LAWS: <br /> OF CALIFORNIA <br /> ApplkanrsSlgnature � ft �`�'U"`�" � r' " ctt 0 Compliance Officer Date 6121 /2019 <br /> BILLING INFORMATION: <br /> Indicate the responsible party lobe billed for, additional EMD 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 most 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 � to L r V / * ou <br /> ' CL ( 'C { PATE 6/21 /2019 <br /> EH230038 (revised 02120]09) S <br /> IL <br /> � , < . <br />