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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # MERLIN BOWEN 925.551.7555 <br />� <br />Facility Name CHEVRON SS#2307709 <br />Phone #209.830.0370 <br />I <br />L <br />Address 10858 TRINITY PARKWAY, STOCKTON <br />I <br />T <br />Cross Street W EIGHT MILE ROAD <br />Y <br />Owner/Operator CHEVRON PRODUCTS COMPANY <br />Phone # 925.842-1000 <br />oContractor <br />Name Gettler Ryan Inc. <br />Phone # 925.551.7555 <br />N <br />T <br />Contractor Address 6805 Sierra Court, Suite G, SUITE G <br />CA Lic # 220793 Class A/B/C61 -D40/CIC <br />A <br />Insurer State Compensation Ins Fund <br />Work Comp #9051229-3 <br />T <br />ICC Technician's Name BRIAN GANN <br />Expiration Date <br />R <br />R <br />Install <br />ICC er's Name MIKE O'SULLIVAN <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i,e. 87 piping sump. 91 leak detector, UDC 1/2. etc.) <br />Installed <br />8K DIESEL/12K 91 GASOLINE <br />8K/12K SPLIT TANK <br />DIESEL/GASOLINE <br />T <br />A <br />N <br />87REGULAR UNLEADED <br />20,000 <br />GASOLINE <br />K <br />P <br />L Approved Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />O <br />Plan Reviewers Name Cin - Date /O <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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />FOR OWNER 4/16/2018 <br />Applicant's Signature4,--TitleAGENT <br />Date <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 Liddy McKenzie TITLE Project Manager PHONE # 925.551.7555 <br />ADDRESS6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br />SIG <br />EH230038 (revised 07-17-2014) <br />2 <br />um <br />