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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 /> TANK RETROFIT E PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT a COLD STARTJEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Facility Name Shell Tesoro Phone# 209-369-3124 <br /> Address <br /> L 2448 W Kettleman Lane, Lodi, Lockeford CA 95242 <br /> I Cross Street Lower Sacramento <br /> T <br /> Y Owner/Operator Tesoro Corporation Phone# 253-896-8809 <br /> o Contractor Name Able Maintenance, Inc. Phone# <br /> N Contractor Address g y 707-545 5522 <br /> 7 3224 Regional Parkway, Santa Rosa 95403 CA Lic# 312844 <br /> R Class g A C10 HAZ <br /> Insurer <br /> A Insurance Company of the West Work Comp# WPL500060300 <br /> TICC Technician's Name <br /> Expiration Date <br /> RICC Installer's Name <br /> Expiration Date <br /> Tank system work area <br /> (i.e 87 piping Tank Size Chemicals Stored Current) Date UST <br /> pipingsump,91 leak detector,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approved Approved with conditionsDisapproved <br /> L ID <br /> A (See Attachment With Conditions) <br /> N Pian Reviewers Nam <br /> � if,_ Date <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 CERTIFYTHAT UBJECT <br /> 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 S <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 /> Applicants Signature Itt .LL 'E.�' ',(�.fi1ue Compliance Officer Date 2/28/2011 <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.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 /> ADDRESS 680 Quinn Ave. San Jose, 95112 L <br /> SIGNATURE 'I'l.1l..Azc�, Li �J L [(r t it (� (� DATE 2/28/2011 <br /> EH230038(revised 02/20/09) <br /> 1 <br />