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ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,Califortnia 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 E PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact+'t Telephone#Marty Weithman 408-213-6038 <br /> AFacia' Name <br /> C �' Chevron Phone# 209-825-0174 <br /> 1 Address <br /> L 1103 S.Main St, Manteca CA 95337 <br /> I Cross Street <br /> Y Owner/operator Chevron US Phone# <br /> 209-825-0174 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> 0 Y 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA tic# 485184 GlassB C61/D40 HAZ <br /> R Insurer <br /> A Cypress Insurance Company Work Comp# 3310020636091 <br /> C ICC Technician's Name <br /> T Chris McKenna Expiration Data 3/19/2011 <br /> R ICC Installer's Name Expiration Date <br /> Tank system Work area Tank Sire Chemicals Stored Current Date UST <br /> (Le.e7 pipfnp sump.81 Aehmtm,UDC t2,etc.) Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ®Approved Approved with conditions Disapproved <br /> L Attachment With Conditions) <br /> A <br /> N Pian Reviewers Name i <br /> 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 TO SECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.` <br /> Compliance Officer <br /> Applicanrs Signature ide bate 1/24/2011 <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 2 k) P a DATE 1/24/2011 <br /> EH230038(revised 02/20/09) <br /> 1 <br />