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ENVIRONMENTAL LDEPARTMENT <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 /> ® TANK RETROFIT ® PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Chevron Phone# 209-931-2186 <br /> 1Address <br /> L 4344 Waterloo Rd Stockton CA 95215 <br /> I Cross Street <br /> Y Owner/Operator Chevron USA Phone# <br /> 209-931-2186 <br /> C Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CALie# 485184 ClassB C61/D40 HAZ <br /> A Insurer ICW Group Work Comp# WPL502130700 <br /> T ICC Technician's Name Michael Briggs Expiration Date 7/12/2013 <br /> O ICC Installer's Name <br /> R Expiration tate <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping swnp,01 Mak detemn,UDC V2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ®Approved pproved With conditions 12 Disapproved <br /> L <br /> A (See Attachment ith CondDate <br /> //4L <br /> N Plan Reviewers Name !l/ 2 "'/Z 12 <br /> ate <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY& INANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN 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 EECOME SUBJECT <br /> TO WORKERS 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 Signa tt re Compliance Officer Date 10/22/2012 <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 �l ' - - � � DATE 10/22/2012 <br /> EH230038(revised 02/20/09) <br />