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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 /> TANK RETROFIT PIPING REPAIR/RETROFIT a UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Speedway Phone # <br /> I 209-369-3124 <br /> L Address 2448 West Kettleman Lane , Lodi , Ca 95242 <br /> T <br /> Cross Street Lower Sacramanto <br /> Y Owner/Operator Speedway LLC Phone # 209-369-3124 <br /> C Contractor Name Service Station Systems , Inc Phone # 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Ave , San Jose CA 95112 CA Lic # 485184 ClassB , C61 /D40 Wb <br /> R A Insurer Oregon Mutual Insurance Company <br /> Work Comp # 4046603 <br /> cICC Technician's Name <br /> T Kristo her Bell Expiration Date 7/22/2024 <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored CurrentlyDate UST <br /> (i.e 87 piping Gump, 91 leak delecloi , UDC 1 /2 , etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> 2100, <br /> P Approved EJ Approved with conditions M Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date k 0 h p "Z� <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.' I / <br /> Applicant's Signature '' v ' Ige Compliance Officer Date 8/ 18/2023 <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 . San Jose , <br /> /95112 <br /> SIGNATUREDATE <br /> 8/ 18/2023 <br /> EH230038 ( revised 02/20109) <br /> 1 <br />