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0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUINCOUNTY <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 /> ® TANK RETROFIT ® PIPING REPAI ETROFIT 8 UDC REPAIR/RETROFIT [I COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> c Facility Name Chevron Phone# 209-478-5555 <br /> 1Address <br /> L 2905 W Benjamin Holt Dr <br /> I Cross Street 1-5 <br /> T <br /> Y Owner/Operator Chevron USA Phone# <br /> 925-287-7182 <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 Lic# 485184 Classg C61/D40 HAZ <br /> R Insurer Company A Cypress Insurance Com an Work Comp# 3310020636091 <br /> T ICC Technician's Name Matt Estabrook Expiration Date 5/28/2011 <br /> R ICC installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current Dale UST <br /> (i.e.87 piping awnp,91 Ink deteclw,UDC 12,etc.) Currently Installed <br /> T <br /> A ®` <br /> N <br /> K <br /> P ® Approved Approved with conditions ID Disapproved <br /> A <br /> A Attachment With Conditions) <br /> N Plan Reviewers Name Date_ <br /> APPLICANT MUST PERFORM ALL W90K 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: '1 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 TOSECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS 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 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> AppiicenrsSignature Compliance Officer ®ate 9/14/2010 <br /> BILLING INFORMATION: <br /> Indicate the responsible patty 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 s DATE 9/14/2010 <br /> EH230038(revised 02/20/09) <br /> i <br />