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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : ( 209 ) 468 -3420 Fax : (209) 468 - 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 130 DAPS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/ RETROFIT D UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE — <br /> �1= EPA Site # <br /> —_Project Contact & Telephone # Emily Crain 910 371 -?380 <br /> Phone # 209 - 234 - 2500 <br /> Facility Name Chevron Lathrop <br /> Address 444 Mossdale Road , Lathrop , CA <br /> L -- <br /> I cross Street West Side Freeway -- <br /> T Phone # g1 &708.I <br /> Y Owner/Operator Pal Dhaliwal Phone # 916- 371 - 2380 <br /> C Contractor Name BZ Maintenance class <br /> N Contractor Address PO Box 933 , West Sacramento , CA 95691 CA Lic # See attached <br /> T Work Comp # <br /> R Insurer See attached <br /> A Expiration Date <br /> CICC Technician' s Name See attached <br /> Expiration Date _ <br /> o ICC Installer' s Name See attached <br /> R ---- Date UST <br /> i Tank system work area Tank Size Chemicals Stored Currently Installed <br /> in $ <br /> w 9i iaak Ce;©clo: . UDC tG etc.) �— <br /> p e 87 PSP 9 T�• V <br /> T <br /> N T <br /> I< <br /> r <br /> I <br /> ^; <br /> Disapproved i <br /> App Ve Approved with conditions 1 <br /> p ( See Attachment With Conditions ) <br /> L 7 / 312c) <br /> A Date <br /> I N Plan Reviewers Name I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCCRDANCE WITH SAID JOAQUIN COUIJTY ORDINANCES. STATE LAWS, <br /> AND RULES AND REGULATIONS Or SAN f <br /> JOAQUIN COUNTY , ENVIRON MENTAL HEALTH DEPARTMENT . OWNER OR LICENSED AGENT 'S 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 IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> SHALL EMPLOY PERSONS SUBJECT TO ORK _ R'S COMPENSATION LAWS <br /> WORKER'S PERFORMANCE <br /> COMPEJS?F THE ORIII FOR <br /> CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br /> THAT IN THE PERFO • MArJCE � F THE WORK FOR 4VI11CH TI115 PERMIT IS ISSUED , I � � <br /> OF CALIFORNIA ." I / (� iFI <br /> L� - . <br /> JTitle ! / ' ` Date <br /> ApplicantI Signature <br /> �J BILLING INFORMATION : <br /> d If <br /> Ind cate he <br /> 3i Onaied l bpowy i o bue Dllleed nt i0aadd;t�o Polrm tD ppaffalnt, 0 .9 P oPd I owner , he ppatty musty ac K owledgee Per ktills / <br /> the party 9 <br /> responsibility for the billing by signature a`{nd date below. 'FII u ( 0 b <br /> �/ `/V CMF _TITLE ` \i� PHONE # <br /> NAME•_ <br /> ADDRESSD ATE <br /> SIGNATURE <br /> -- - < <br /> EH230038 (reviser) 12 . 11 - 15) <br />