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SAN J O A QU IN <br /> Environmental Health Department <br /> OUN <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Christina Tran 408-213-6039 <br /> � Facility Name Teichert 4 Phone # 916-717-2176 <br /> I Address 120 Frank W Circle, Stockton, CA 95206 <br /> I Cross Street _ <br /> T -- -- - - ---- -- _ <br /> Y Owner/Operator Nic Armstrong Phone # 916-386-3735 <br /> c Contractor Name Service Station Systems, Inc Phone # 408-971-2445 <br /> N Contractor Address 680 Quinn Ave, San Jose, CA 95112 CA Lic# 485184 Class ass B C61/D40 HAZ <br /> R Insurer Work Com # <br /> A 1 c-VV.esL....._ p WLV5.07821801 <br /> c ICC Technician's Name <br /> T see attached Expiration Date <br /> o [CC Installer's Name Expiration Date <br /> R see attached p _ <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector, UDC 112,etc.) Installed <br /> T <br /> A <br /> N -- --_ - <br /> K <br /> P X Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �e At/t.-Ij a Date l0 C1 /25 <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: "I 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF T E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature _Title Project and Permit Coordinator Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e,g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME ChrlsUna Tran TITLE Project and Permit Coordinator PHONE #— 408-213-6039 <br /> 680 Quinn Ave, San Jose, Ca 95112 <br /> ADDRESS <br /> SIGNATURE DATE <br /> 3 of 6 <br />