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A ® i <br />SAN JOAQUIN O <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 780 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />® TANK RETROFIT ® PIPING REPAIRIRETROFIT ® UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br />F <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 Stree l Elm St <br />Y <br />Owner/Operator Tesoro Corporation <br />253-896-8809 <br />C <br />Contractor Name Able Maintenance, Inc. <br />=707-545-5522 <br />TN <br />Contractor AddressRegional Parkway, Rosa 95403 <br />CA Lic# 312844 Class B A C10 HAZ <br />RInsurer <br />A <br />Insurance Company of the West <br />Work Comp # WPL500060300 <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />IIs. a7Mpmosump. ®1 ae�or,ubC,a,etc.1 <br />Tank Size <br />Chemicals Stared Current <br />Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />® Approved ppmved With conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />j <br />Pian Reviewers Name Date f/ % �l <br />7 <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 1N SUCH A MANNER AS TO DECOME SUBJECT <br />TO WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 9 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 />Applicants nce Officer vele 2/28/2011 <br />�- • <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 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE_ �f DATE 2/28/2011 <br />EH230038 (revised 02/20/09) <br />1 <br />