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SAN JOAQUIN COUNTY ENVO)NMENTAL HEALTH DEP4VTMENT 304 E WEBER AVE,3R°FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: . W1 �TANK•RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ------------------------------------- ---------------------------------------------------------------------------+ +---� EPA SITE # I �atg7 C-ai�rt��o rZN{.. I PROJECT CONTACT & TELEPHONE # � ' US-S16-417001 t - ---- ---------------------------------------i F I FACILITY NAME # 2D•-611& /v be�bn 17rpI du6ts 60. PHONE # I A +------------------------------------- ---------- ----------{--------------------------------------------------i C I ADDRESS 33515 a. Fkj,v &- Lena �T� --oGk1D>n i °t5212- I +-----------------------------------------------------------------------------------------------------------------------------I L I CROSS STREET µp1rn.,,-t Rd . I +------------------------------------------------------------------------------------i PHONE #--------------------------------i j T I OWNER/A2HRPlFBh I Y I chevron Products Co. (Attn: David Lyons I (925)$42-4387 C I CONTRACTOR NAME 59,/id-3e, Constructian , Inc. I PHONE # (530) (022- (982 I O +-----------------------------------------------------------------------------------------------------------------------------I I N I CONTRACTOR ADDRESS .4401 5Dnj2 GDurt,FlWrV;11di CA LIC # 75589$ I CLASS A , HAS• I IT +-----------------------------------------------------------------------------------------------------------------------------I R I INSURER 5+gte (_0M1vCnS2ti611 IV'30ranc4t Fund IomcoMP.# 273-2003 1 ----------------------+W--------------------------------------I I C I OTHER INFORMATION I 0 i-- -----------------------------------------------------------------------"----- _I I PHONE # I IR +-------------------------------------------------------------------------------=----+----------------------------------------I I I PHONE # I +---I111111111111Illlllllllllllillll----------------------------------------------------------------------------------------------I I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 139- DI I 2-0,004 I r<AynI I 1aR� I T 139- d I S.oU0 I_bfGM. LJr1 I . I I'199 I IA139- I I I I N 1 39- K 9-K I 39- 39- 39- P 9-39-39-P L I _APPROVED APPROVED WITH CONDITIONS) DISAPPROVED I I pT!l )1 A OA� ATTACH6.ISNNT WITH CObIDITIONS) N I PLAN REVIEWERS NAME I U�I_ DATE O — +___I11i1II111iilIIIIIIIIII IIIIII111 IIIIIIIII� IIIIIIIiIi�il�iillll11I11IlIIIII{IIII1{IIIIIIIIIIIII{I I I1 IIIII I11IiI�IiIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I THAT IN.THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I _A- A9�t' �ib�Chevron 7/Z 1 { APPLICANT'S SIGNATURE: TITLE I R L ic-Z�ro��-fnG. I +---------------------------------------------------------------------------------------------------------------------------------+ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name�NL Df–. n &Ou In4.Address–040 �lrnvld Df. `0 ho I'larfi net_Phone# 925'313'"`700 °�-- –4'-�--- — 94553 ext Io? Signatur -r;^ aunt fo' Gl vroom, 4L EH230038 1 (revised 1/31/02)