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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Fast 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 THEAPOROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT10 PIPING REPAIRMETROFIT B UDC REPAIR/RETROFIT COLD .STARTIEVR UPGRADE <br /> F EPA Site # Project Contact . & To # Marty. Weithman 408-213-6038 <br /> A Facility Name Phone <br /> C ty Chevron #208117 209-830-0370 <br /> I Address <br /> L 755 S Tracy Blvd , Tracy CA 95376 <br /> 7 Cross Street <br /> Y Owner/Operator Chevron Phone # 209 -830-0370 <br /> c Contractor Name Service Station Systems , Inc Phone # 408-213-6038 <br /> 0 <br /> N Contractor Address 680 Quinn Ave , San Jose CA 95112 CA Lia # 485184 Class <br /> T B C61 /D40 <br /> A Insurer Insurance Company of the West Work Comp# WPL 5021307 <br /> C ICC Techniclan's Name Bpiration Dale <br /> a ICC . Installer's. . Name Expiration Date <br /> Tank system work areaDate UST <br /> (Ce 87 piping sump, 91 leak detector, UDC 1n, e1a.l Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L (S achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK -IN ACCORD 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 : 11 CERTiFY'THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 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:` ` , t <br /> e V 1�C t me Compliance Officer D81e 5/8!2019 <br /> ApplicanrsSignalur <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 /> responsibillty 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 M / LtiV L ,E� "LU- [ o4� DATE 5/8/2019 ,1 rf? III <br /> I <br /> EH230038 (revised 02/20/09 ) j ] <br /> 1 [YY 7 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />