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f <br /> 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 E PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site# Project contact&Telephone#Marty Weithman 408-213-603 <br /> A <br /> C Facility Name <br /> Addressn Phone# 209-931-2186 <br /> Waterloo Rd <br /> I Cross Streel <br /> Y Owner/Operator Chevron USA Phone# 209-931-2186 <br /> C Contractor Name Service Station Systems Phone# 408) 213-6038 <br /> N Contractor Address 680 Quinn Avenue CA Lic# 485184 Class B C61/D40 HAZ <br /> A Insurer Cypress Insurance Company work Comp# 3310020636081 <br /> C ICC Technician's Name <br /> T Jarrett Flewell n Expiration Date 6/4/2011 <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Std Current) Date UST <br /> Stored(i.e 87 piping Sump.91 leek detector,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P EJ Approved dgkpproved with conditions l!J Disapproved <br /> L ,.(See�4ttachment With Conditions) <br /> A <br /> N MYl/ f ,(( <br /> Pian Reviewers Name1A Da <br /> to <br /> If <br /> APPLICANT MUST PERFORM ALL WORK INA CORDANCE WITH SAN JOA O11IN COUNTY RDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO'BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "l 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 /> fmom Mance vmcer <br /> Applicanrs signaILn Lut CZL t u c -erre p Daae 9/15/09 <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 Martv Weithman TITLE Compliance Officer PHONE# (408) 213-6038 <br /> ADDRESS 680 Quinn Avenue San Jose, CA 95112 <br /> SIGNATURE 1'i`.I LLI.t �v �' / �CPt-t I.0 -f L/ DATE 9/15/09 <br /> EH230038(revised 02/20109) <br /> 1 <br />