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t�rvs <br />ENVIRONMENTALTFC DEPAPT <br />bAnIva 0 0 1 0 5 <br />600 .East: Main Street, Stockton, California 95202 <br />Telephone: (249) 468-3420 Fax: (209) 468-3433 <br />Hill <br />AN.i6i,*ieguu; , Wt iv 'r' <br />n:: ALTRI 9 E{'; ,:r, e i TENT <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR P'IP'ING REPAIR PERMIT <br />THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />ANN RETROFIT ilPING REPAIPJRETROFtT DUDG REPAIRIRETROFI-F DOLD sTARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Eric Janzen (707) 293-2586 <br />� <br />Facility Name Tesoro/Shell #558151 <br />Phone #209 369-1525 <br />Address 35 North Cherokee Lane, Lodi CA <br />Cross Street Elm Street <br />Y <br />Owner[OperatorTesoro Refining & Marketing Phone # <br />C <br />0 <br />Contractor Name RSSE, Inc Phone #530 241-1275 <br />N <br />T <br />Contractor Address 823 Turin View Blvd. Redding CA 35003 <br />CA Lic# 957228 Class A, 6, 010. HAZ <br />R <br />A <br />InsurerDelos Insurance Company <br />Work Comp#01DKRM12009586 <br />c <br />T <br />ICC Technician's NameJohn Jackson <br />Expiration Date2f23/Z013 <br />R <br />ICC Installer's Name John Jackson <br />Expiration Date 5112/2013 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />date UST <br />Installed <br />CLe. 3T pip&rg sump, 91 leak detector, UDC 112, etc.} <br />68151 Premium(91) fill/vapor <br />10,000 <br />gasoline <br />T <br />A <br />N <br />K <br />p <br />❑ Approved Approved With conditions ❑ Disapproved <br />L <br />With Conditions) <br />A <br />tj(tSAachment <br />N <br />Plan Reviewers Mame Date_ Y� <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 PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKERS COMPENSA r LAWS OF CALI A." CONTRACTOR'$ HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: i CERTIFY <br />WORKER'S COMPENSATION LAWS <br />THAT IN THE PERFOR C OFT RK HICH THIS PERMIT ISISSUED. I SHALL PERSONS SUBJECT TOA - <br />OF CALIFORNIA." <br />ApplOnntsBJgnatuls Trite <br />BILLING INFORMA I iON: <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 biliin by signature and da4elow. <br />NAM E /"^Mce- 6uALkiN TITLE M&A.. Cbn1S+'MvG?% �. FhfONE # <br />1361 la Vista Ave., Concord <br />EH230038 (revised 02/20/09) <br />1 <br />