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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 D PIPING REPAIRIRETROFIT 8 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 Phone # 209-952-2213 <br />1 <br />L <br />Address 10858 Trinity Parkway, Stockton CA 95219 <br />1 <br />T <br />Cross Street Scott Creek Dr. <br />Y <br />Owner/Operator Chevron USA <br />-7182 <br />C <br />Contractor Name Service Station Systems, Inc. <br />E <br />EPhoneEE -6038 <br />EH <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />485184 Class <br />CA Lic # B C61/D40 HAZ <br />RInsurer <br />A <br />Travelers <br />Work Comp # UB6054F2133 <br />cICC <br />T <br />Q <br />Technician's Name Ran Casey <br />Expiration Date 5/2gA2g.l.l—. Iq tom, <br />R <br />ICC Installers Name <br />' <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 Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />i <br />P <br />Approved 1§�Approved with conditions M Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Q <br />Plan Reviewers Nam 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, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 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 <br />CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicanrs Signature G L Lt- L1,LAaT4ne Compliance Officer Date 7/25/2011 <br />v.rr — nom. —111v—I IVII. <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 />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE u v <br />EH230038 (revised 0272-0/09) <br />1 <br />7/25/2011 <br />