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SAN JAQUIN 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 />® TANK RETROFIT @ PIPING REPAIRIRETROFIT ® UDC REPAIRIRETROFIT © COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Shell/Tesoro <br />Phone # 209-369-1525 <br />I <br />L <br />Address 35 N Cherokee Lane, Lodi CA 95240 <br />I <br />T <br />Cross Stree t Elm St <br />Y <br />Owner/Operator Tesoro Refining and Marketing Copany <br />Phone# 253-896-8700 <br />C <br />Contractor Name Service Station Systems, Inc.D <br />Phone# 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />R <br />A <br />Insurer Cypress Insurance Company Work Comp # 3310020636091 <br />C <br />T <br />ICC Technician's Name Randy Wilkerson Expiration Date 5/19/2013 <br />R <br />ICC Installer's Name Expiration Date <br />Tank system work area <br />{7.e 87 piping amv, 81 Mak deWw, UDC 1Q,etr-) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved Approved With conditions Disapproved <br />L <br />A <br />(S Att went With Conditions) <br />N <br />Pian Reviewers Name <br />-2Q& Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAOUIN 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 1N SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />AppUcetUsSignat+xeq -tA-- Wk Compliance Officer fist, 11/1/2012 <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 OfficerPHONE# (408) 213-6038 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE " t1- �} i RATE 11/1/2012 <br />EM230038 (revised 02/20/09) <br />1 <br />