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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 />❑TANK RETROFITE�PIPING REPAIR/RETROFIT ®UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Eric Janzen (707) 293-2986 <br />� <br />Facility Name Shell #68151 <br />Phone #209-369-1525 <br />I <br />L <br />Address 35 North Cherokee Lane, Lodi CA 95240 <br />TCross <br />Street Elm Street <br />Y <br />Owner/Operator Tesoro Refining & Marketing <br />Phone # <br />o- <br />Contractor NameAble Maintenance, Inc. <br />Phone#707 293-2986 <br />Contractor Address 3224 Regional Parkway, Santa Rosa, 95403 <br />CA Lic # 312844 Class A, B, C10, HAZ <br />T <br />A <br />Insurer Insurance Company of the West <br />Work Comp # WPL500060303 <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name Kelly Bumingham 5250610 <br />Expiration Date4#8fi943- /d/ -7 &0/g <br />Tank system work area <br />detector, UDC W, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak etc.) <br />68151 Diesel <br />10,000 <br />Diesel <br />T <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />N <br />AAv�014 <br />_ <br />Plan Reviewers Name Date <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 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 <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 CALIFORNI <br />Code Compliance Officer 3/16/2012 <br />Applioarrt ignature�J Title Date <br />BILLING INFORMATION: <br />Indicate the responsible pait'j/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 Eric Janzen TITLE Code Compliance Officer PHONE # 707-293-2986 <br />3224 Regional Parkway, Santa Rosa CA 95403 <br />