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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 U PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B 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 />L <br />Address y <br />10858 Trinity Parkwa <br />I <br />T <br />Cross Street Scott Creek Dr. <br />Y <br />Owner/Operator Chevron USA <br />Phone # 925-287-7182 <br />Qc <br />Contractor Name y <br />Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />NContractor <br />T <br />Address 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />RA <br />Insurer Travelers Prop and Cas <br />Work Comp # UB6054F2133 <br />cICC <br />T <br />Technicians Name <br />' Randy Wilkerson <br />Expiration Date 5/19/2013 <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />i' <br />P <br />Approved _I�4pproved with conditions D Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Nam ��G�C/'��G•y^ Date <br />APPLICANT MUST PERFORM ALL ORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONM AL 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: "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 />Applicanrs Signature', t L lL� car tIge Compliance Officer Date 5/02/2012 <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 # (408) 213-6038 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE 11 (d Lr4_ AC, L' - � � _)_C, DATE 5/02/2012 <br />EH230038 (revised 02/20/09) <br />1 <br />