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0 <br /> ENVIRONMENTAL HEALTH DEPA=RTMENT <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 /> L� TANK RETROFIT Ia PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT 9 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# 209-477-3699 <br /> 1 ss Addre <br /> L 3355 Hammer Lane,Stockton CA 95212 <br /> TCross Street <br /> Y Owner/Operator Chevron USA Phone# <br /> 209-477-3699 <br /> o Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> N Contractor Address 485184 Classg C61/D40 HAZ <br /> T 680 Quinn Avenue CA Lic# <br /> R Insurer <br /> A Cypress Insurance Company Work Comp# 3310020636091 <br /> C ICC Technician's Name <br /> T Chris McKenna Expiration Date 3/19/2011 <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leakdelector,UDC 1n,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved e19 Approved With conditions 0 Disapproved <br /> L S Attachment With Conditions) <br /> A <br /> N Pian Reviewers NameD <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: 'I 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." CONTRACTORS 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 Signature Q- 4 �` ✓y�l { srt u tr Compliance Officer D,1, 1/14/2010 <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 /> SIGNATURE11i BLI,tLTL,' �-1 � '���-d��t-� DATE 1/14/2010 <br /> EH230038(revised 02/20/09) <br /> 1 <br />