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• <br />0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 />C TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name Shell Tesoro Phone # 209-369-1525 <br />1 <br />L <br />Address 35 N Cherokee Lane, Lodi CA 95240 <br />I <br />T <br />Cross Street Elm St <br />Y <br />Owner/Operator Tesoro Refining and Marketing Copany <br />Phone # 253-896-8700 <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />NContractor <br />T <br />Address 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />A <br />Insurer ICW Group <br />Work Comp # WPL502130700 <br />TICC <br />T <br />Technician's Name Matt Estabrook <br />Expiration Date 5/19/2013 <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />{i.e. 87 piping Bump, 81 leak detectpr, UDC 12, ea.l <br />Tank Size <br />Chemicals Stored Current <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved MIApproved With conditions In Disapproved <br />L <br />A <br />N <br />Aria t With Conditions) <br />f <br />Plan Reviewers Name Date l <br />b <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 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />ApplksnrsSignatureL « w V � t %u t'r Compliance Officer Date 2/15/2013 <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 6)80 Quinn Ave. San Jose, 95112 <br />SIGNATURE /�� ��� �-L�1 �lL-f —L, lam` DATE 2/15/2013 <br />EM230038 (revised 02120/09) <br />F� <br />