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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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ]COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C Facility Name Tesoro#68221 Phone# <br /> I Address <br /> L 2705 Country Club Blvd. Stockton CA 95204 <br /> TCross Street <br /> Y Owner/Operator Tesoro Phone# <br /> C Contractor Name Walton Engineering,Inc. Phone# 916-373-1165 <br /> 0 <br /> N <br /> T Contractor Address P.O.Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp# 9113339-2017 <br /> C ICC Technician's Name Expiration Date <br /> T Michael Raymond-8156309 p 3-28-2019 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T Install New TLM. Cold-Start <br /> A <br /> N <br /> K <br /> P ❑ Approved aApproved with conditions ❑ Disapproved <br /> L chment With Conditions) <br /> A i <br /> N Plan Reviewers Name C`ys 't Date �� d^� `� <br /> UP <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD E WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL 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 /> WORKER'S COMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title �r' Date I _ r s- <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 M 1L�.o e ll, WCC 01 //�� TITLE Prc� PHONE# <br /> N <br /> ADDRESS •U , 13n X 10-2—S G J C-S+ 4 <br /> SIGNATURE < DATE { <br /> EH230038(revised 7-26-2016) 2 <br />