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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 />® TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br />A F <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Chevron <br />Phone # 209-836-3181 <br />1Address <br />L <br />1960W 11th St, Tracy CA 95376 <br />I <br />T <br />Cross Street Corral Hallow <br />Y <br />Owner/Operator Chevron USA <br />Phone # 925-287-7182 <br />C <br />Contractor Name Service Station Systems, Inc.Q <br />Phone # 408-213-6038 <br />N <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Class B C61/D40 HAZ <br />R <br />Insurer p <br />Travelers Pro and Cas <br />Work Comp # UB6054F2133 <br />C <br />T <br />ICC Technician's Name Matt Estabrook <br />Expiration Date 5/19/2013 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(he. 87 plpinp Pump, 91 Ink deleder, UCC 1/2, etc.) <br />Tank Size Chemicals Stored Current <br />Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved Approved with conditions 12 Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />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: 9 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 TO13SCOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: `I <br />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 />Applicanrasigneture Compliance Officer mt. 12/12/11 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment overage 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 6810 Quinn Ave. San Jose, 95112 <br />' <br />SIGNATURE "It j L�.L. <br />�.,/ V / . <br />EM230038 (revised 02120109) <br />111 <br />12/12/11 <br />