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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 />8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT a UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name Chevron <br />Phone # 209-952-2213 <br />1 <br />L <br />Address y <br />10858 Trinity Parkway, Stockton CA 95219 <br />1 <br />T <br />Cross Street Scott Creek Dr. <br />Y <br />Owner/Operator Chevron USA <br />Phone # 925-842-9002 <br />o <br />Contractor Name Able Maintenance, Inc. <br />Phone # 707-545-5522 <br />N <br />T <br />Contractor Address 3224 Regional Parkway, Santa Rosa 95403 <br />CA Lic # 312844 Class B A C10 HAZ <br />R <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WPL500060304 <br />cICC <br />T <br />Technician's Name Mike Trejo <br />Expiration Date 4/15/2013 <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 iuk detector, uoc 1n, etc.)y <br />Tank Size Chemicals Stored Current) <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved /'Approved with conditions 0 Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date / <br />APPLICANT MUST PERFORM ALL WOAK 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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 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 />ApplicanrsSignat ,1.ti �t�Gr LLL (�.tiTy1e Compliance Officer Date 12/27/2012 <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 11 (408) 213-6038 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE L�l <br />t.1.l-k-A.CJ DATE 12/27/2012 <br />EH230038 (revised 02/20/09) <br />1 <br />