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0 <br /> ENVIRONMENTAL HEALTH DEPARWtIVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 JA.i Q 5 317 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANRf DEPARTMENT HEALTH <br /> TAL IAL <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name Tesoro#68154 Phone# (209) 366-0703 <br /> I <br /> L Address 2500 W.Lodi Avenue <br /> TCross Street W. Sargent Road <br /> Y Owner/Operator Tesoro Refining&Marketing Co.LLC Phone# (210) 626-6674 <br /> D Contractor Name Walton Engineering Inc. Phone# (916) 373-1152 <br /> 0 <br /> N Contractor Address P. O. Box 1025,West Sacramento CA Lic# 617238 Class A,B,Haz <br /> T <br /> R Work Com # <br /> A Insurer See Attached p <br /> C <br /> r ICC Technician's Name Expiration Date <br /> 0ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 12,etc.) Installed <br /> T 91 Leak Detector <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L /� ( a AAy/acchhmantt V ith Conditions) ./J1 <br /> N Plan Reviewers Namee.��U I ' rv�c� 1 t �L `7 Date t "t <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 AGENTS 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE WORK FOR WHI THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title Contractor Date — - <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 Michael Walton TITLE <br /> President PHONE# (916) 373-1152 <br /> ADDRESS P. O. Box 11025,West Sacramento,CA 95691 <br /> SIGNATURE DATE Y <br /> EH230038(revised 7-26-2016) 2 <br />