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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 /> 8 TANK RETROFIT 0 PIPING REPAIRfRETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> P EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name USA Phone# 209-369-3124 <br /> IAddress <br /> L 2448 W Kettleman Lane <br /> I Cross Street Lower Sacramento <br /> T <br /> Y Owner/Operator Tesoro Refining and Marketing Copany Phone# 253-896-8700 <br /> o Contractor Name Service Station Systems,Inc. Phone# 408-213-6038 <br /> N Contractor Address 680 Quinn Avenue CA Lic# 485184 Ciassg C61/D40 HAZ <br /> T <br /> R <br /> A Insurer Cypress Insurance Company Work Com # <br /> 3310020636091 <br /> T ICC Technician's Name Randy Wilkerson Expiration Dale 5/26/2011 <br /> R <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Dale UST <br /> (i.!97 piping sump,91 leak deledw,1100 W,W..) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ej Approved %Approved with conditions Disapproved <br /> (See Attachment With Conditions) <br /> N Plan Reviewers Namef, t� 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 W SUCH A MANNER AS TO13ECOME SUBJECT <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 /> Appllcanrc Signature/' � —- ). y�I� B Compliance Officer D1, 5/2512010 <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 i= i•-� '� III DATE 5/25/2010 <br /> EH230038(revised 02/20/09) <br /> 1 <br />