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0 <br />• <br />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 [0 PIPING REPAIR]RETROFIT 8 UDC REPAIRIRETROFIT Ej COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact 8 Telephone # Marty Weithman 408-213-6038 <br />A <br />C <br />Facility Name Chevron <br />Phone # 209.599-0149 <br />1 <br />L <br />Address 1442 A Colony Dr and Hwy, Ripon CA 95366 <br />TCross <br />Street <br />Y <br />Owner/Operator Chevron USA <br />Phone # 925-287-7182 <br />r0 <br />Contractor Name Service Station Systems, Inc. <br />Y <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />CA t.ic # 485184 Classg C61ID40 HA2 <br />R <br />A <br />Insurer Travelers Prop and Cas <br />Work Comp # Ug6054F2133 <br />C <br />T <br />ICC Technician's Name Matt Esiabrook <br />Expiration Date <br />p <br />R <br />ICC Installer's Name <br />_5!1912013 <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stared Current! y <br />Date UST <br />p.e 87 piping sump, 91 leak detectnt, UDC M2, ett.j <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved .0 Approved with conditions I2 Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />! <br />Plan Reviewers Name 14 �-Date_ _ t' 2 <br />APPLICANT MUST PERFORM ALL WORK 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." CONTRACTORS 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.' m` �( l <br />Applicants Signature r�t�LL'"`- U1 - ! b tj-tt�i r i w / tidlae Compliance Officer ,et, 1!2312012 <br />BILLING INFQRMIA I JUN; <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank, tf <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 />Martv Weithman <br />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE -JA <br />EH230038 (revised <br />Compliance Officer <br />1 <br />(408) 213-6038 <br />1!23!2012 <br />