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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 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT 10 PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F FFacililylName <br /> A ie# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Shell Tesoro Phone# 209-369-3124 <br /> 1Address <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 /> c Contractor Name Able Maintenance, Inc. Phone# <br /> 707-545-5522 <br /> N T Contractor AddressRegional Parkway, <br /> Santa Rosa 95403 CA Lic# 312844 Class g A C10 HAZ <br /> R A Insurer Insurance Company <br /> of the West Work Comp# WPL500060300 <br /> T ICC Technician's Name <br /> Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump,91 leak detector.UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> Approved <br /> L Approved with conditions Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Nam c 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 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 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." J', <br /> Applicant's Signature t,�• /V E lvllne 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 <br /> SIGNATURE V�� C.t_ZU;- L1DATE <br /> 2/28/2011 <br /> EH230038(revised 02/20/09) <br /> 1 <br />