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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 APR 15 2011 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PW=VP R1-FEMW <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: IT(SERVICES <br />8 TANK RETROFIT 10 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 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 # 925-287-7182 <br />o <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Class B C61/D40 HAZ <br />R <br />A <br />Insurer pCompany <br />Cypress Insurance <br />Work Comp # 3310020636091 <br />cICC <br />T <br />Technician's Name Matt Estabrook <br />Expiration Date 5/28/2011 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 97 piping sump, 91 leak delector, UDC U2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved p roved with conditions In Disapproved <br />L <br />A <br />(See Ari ent With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL VY64ORK 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 />Appllcanrs Signature '' �� � � �4_t tA aL fit, Tine Compliance Officer Date 4/14/2011 <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.9, 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 />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE l� ('�L-L'� �, ( r t �Ct -ti �_�.J DATE 4/14/2011 <br />EH230038 (revised 02/20/09) <br />1 <br />