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V <br /> 05 2017 <br /> E N V HP C-1,N ivl,E L 1- <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> n ILE 600 East Main Street,Stockton,California 95202 <br /> U1 r I <br /> FILE f�t 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 /> Ia TANK RETROFIT El PIPING REPAIR/RETROFIT El UDC REPAIR/RETROFIT 11 COLD BTARTIEVR UPGRADE <br /> F EPA Site# —Project Contact&Telephone# Merlin Bowen (925.551.7555) <br /> A <br /> c Facility N meCHEVRON SS#2081 18 Phone# 925-842-1000 <br /> I <br /> L Address 3355 E HAMMER LANE <br /> I <br /> T Cross street HOLMAN ROAD <br /> Y Owner/Operator CHEVRON PRODUCTS COMPANY Phone# (925)842-1000 <br /> OC Contractor NameWAYNE PERRY, INC. Phone# (916)64&9680 <br /> N <br /> Contractor ontractor Address 30 MAIN AVE.SUITE.5,SACRAMENTO,CA.95838 CA Lic# 300345 CiaSSA,8,CI0,C-61M4QH0Z <br /> K <br /> A insurer TRAVELERS PROP & CASUALTY CO. OF AMERICA Work Comp# 10000019610 <br /> U — <br /> T ICC Technician's Name BRANDON SMITH UST INSTALL Expiration Date 5/30/2018 <br /> 0 <br /> R ICC Installer's Name BRANDON SMITH UST SERVICE Expiration Date 5/30/2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> ri.s�87 pift sump,91 Imk d0ecim,UDC W,em) Installed <br /> T PREMIUM UNLEADED 15,000 91 GASOLINE <br /> A <br /> N <br /> K REGULAR UNLEADED 20,000 87 GASOLINE <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 7 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CO TY 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 SMALL NOT EMPLOY ANY PERSON IN 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 TH K FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applimnrs Signature rroe <br /> AGENT FOR O&LER <br /> BILLING INFORMATION: r <br /> Indicate the 9C--n-sible 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 /> NWEMerlin Bowen (925.551.7555) TITLEPerMit TechPHONE#925.551.7555 <br /> ADDREss6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br /> SIGNATURE JO <br /> DATE�_ <br /> EH230038(revised 02120/09) <br />