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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 10 PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> A F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> Facility Name Shell/Tesoro Phone# 209-369-3124 <br /> I Address <br /> L 2448 W Kettleman Lane, Lodi CA 95242 <br /> I Cross Street Lower Sacramento <br /> T <br /> Y Owner/Operator Tesoro Refining and Marketing Copany Phone# <br /> 253-896-8700 <br /> o Contractor Name Service Station Systems, Inc. Phone# <br /> 408-213-6038 <br /> N Contractor Address 485184 Class <br /> T 680 Quinn Avenue CA Lic# B C61/D40 HAZ <br /> R A InsurerCypress Insurance Company <br /> Work Comp# 3310020636091 <br /> cICC Technician's Name <br /> T BIryan Lundien Expiration Date 10/23/2011 <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Dale UST <br /> (i.e 87 piping sump,91 leak detector,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P EJ Approved Approved with conditions M Disapproved <br /> L e- <br /> A -Approved <br /> With Conditions) <br /> tom ,-2-�I <br /> N Plan Reviewers Name 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.' <br /> Applicants Signature 1(el-IL I I' �,-� � �LLi�cue Compliance Officer Date 5/23/2011 <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 ��f ((CC-(,r LA L) l t Lit--L�) DATE 5/23/2011 <br /> EH230038(revised 02/20/09) <br /> 1 <br />