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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 n PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <br />c <br />Facility Name USA(Tesoro <br />Phone # 209-368-8787 <br />1 <br />L <br />Address 401 W. Kettlman Ln, Lodi CA 95240 <br />I <br />T <br />Cross Street Hutchins <br />Y <br />Owner/Operator Elizabeth Okupe <br />Phone # 209-231-9130 <br />C <br />Contractor Name Able Maintenance, Inc. <br />Phone # 707-545-5522 <br />N <br />T <br />Contractor Address 3224 Regional Parkway, Santa Rosa 95403 <br />CA Lic # 312844 Class B A C10 HAZ <br />AInsurer <br />State Compensation Insurance Fund <br />Work Comp # 9073219-13 <br />C <br />ICC Technician's Name <br />Expiration Date 11 /18/2014 <br />Q <br />R <br />ICC Installer's Name Kelly Burningham <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with conditions 0 Disapproved <br />L <br />A <br />(Ste Attachment With Conditions) <br />N <br />` <br />Pian Reviewers Name Date - l <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 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 />j <br />1 <br />-Applicants Signature. 6 6 (uL L,-1 4- 1 L E `�:lL�ft lie Compliance Officer Date 2/17/20174 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EMD 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 />680 Quinn Ave. San Jose, 95112 <br />SIGNATURE jif l t - At,- � � � P DATE 2/17/2014 <br />EH230038 (revised 02/20/09) <br />1 <br />