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1 0 0 <br />11 ill ijl�111 <br />c i <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 980 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />8 TANK RETROFIT ® PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br />F <br />AFacii <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Name <br />� Shell Tesoro Phone # 209-369-1525 <br />I <br />L <br />Address 35 N Cherokee Ln 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 />C <br />o <br />Contractor Name Service Station Systems, Inc. <br />Y <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />RInsurer <br />A <br />Cypress Insurance Company <br />Work Comp # 3310020636091 <br />C <br />T <br />ICC Technician's Name Bryan Lundien <br />Expiration Date 10/23/2011 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(Le, 87 piping sump. 91 ink detwor, UDC W, eir.) <br />Tank Size Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />pproved with conditions I� Disapproved <br />® Approved4chment <br />L <br />A <br />With Conditions) <br />N <br />0� <br />Pian 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 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: "1 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 />Applicenrs SignsWu U ' Ige Compliance Officer Dais 1/20/2011 <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 a,1Ja ; DATE 1/20/2011 <br />EH230038 (revised 02/20109) <br />FA <br />