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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECE1 <br />600 East Main Street, Stockton, California 95202 <br />Telepbone: (209) 468-3420 Fax: (209) 468-3433 DEC 14 2011 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIP%"f0 W*MM1T <br />x:Q,111:�Sc i'Jif: ;3 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Chevron Phone # 209-836-3181 <br />1 <br />L <br />Address y <br />1960 W 11th St, Trac CA 95376 <br />1 <br />T <br />Cross Street Corral Hallow <br />Y <br />Owner/Operator Chevron USA <br />Phone # 925-287-7182 <br />o <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />RInsurer <br />A <br />Travelers Prop and Cas <br />Work Comp # U136054F2133 <br />T <br />ICC Technician's Name Matt Estabrook <br />Expiration Date 5/19/2013 <br />oICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(Le. 87 piping sump, 91 leak detector, UDC W, etc.) <br />Tank Size <br />Chemicals Scored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />EJ Approved Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Namec �„ra, 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: -1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N 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 Signatlme b �t� �Ttue Compliance Officer Dat, 12/12/11 <br />DILLIIV%.t IIVFORIVIA 1 ION: <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 <br />EH230038 (revised 02/20/09) <br />1 <br />12/12/11 <br />