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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 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW - <br />0 TANK RETROFIT ® PIPING REPAIR/RETROFIT t UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site#CAR000201806 <br />Project Contact&Telephone# LUCY SILVASTHOMAS 916-636-9500 <br />A <br />C <br />Facility Name CHEVRON <br />Phone # 2 0 9 - 952 2 213 <br />1 <br />L <br />Address 10858 TRINITY PRKWAY <br />I <br />Cross Street w 8 MILE RD <br />T <br />Y <br />Owner/Operator CHEVRON <br />Phone# 714 671-3499 <br />o <br />Contractor Name TOWN & COUNTRY CONTRACTORS, INC <br />Phone # 916-636 9500 <br />T <br />Contractor Address 3181 LUYUNG DR ST A <br />CALIc#f238112 CIasdiAZ,A,B,C20, <br />R <br />A <br />Insurer STATE FUND <br />UTU <br />Work Comp #392 3128 2008 <br />TICC <br />T <br />Technicians Name LATHAM ZUBILLAGA 5275557UT <br />' <br />Expiration Date 6/16/2011 <br />R <br />' <br />ICC Installers Name LATHAM ZUBILLAGA 5275557U1 <br />Expiration Date 1/10/2012 <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 />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date o <br />APPLICANT MUST PERFORM ALL WOR N 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." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF HE WO f rORWHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO RKE 'S COMPENSATION LAWS <br />OF CALIFORNIA." % <br />Applicant's Sign Tltle PROD ADMIN Date " <br />LSILLINU INF UKIVIA I IUN: <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 LUCY SILVAS-THOMAS TITLE PROJ ADMIN PHONE# 916 636 9500 <br />ADDRESS 3181 LUYJS NG DRIVE STE A, RANCHO CORDOVA, CA 95742 <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />iFiIM <br />36 <br />