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E <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, Caffornia 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 10 PIPING REPAIRJRETROFIT 0 UDC REPAIR/RETROFIT D COLE) START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <br />C <br />I <br />Facility Name USA Phone 4 209-369-1525 <br />L <br />Address 35 N Cherokee Lane, Lodi CA 95240 <br />I <br />T <br />Cross Street Elm St <br />y <br />Owner/Operator Tesoro Refining and Marketing Copany <br />hon 253-896-8700 <br />OC <br />Contractor Name Service Station Systems, Inc. <br />-# <br />Phone # 408-213-6038 <br />I <br />N <br />T <br />R <br />Contractor Address 680 Quinn Avenue <br />CA Lic # 485184 CI8ssB C61/D40 HAZ <br />A <br />C <br />Insurer Cypress Insurance Company <br />Work COITIP # 3310020636091 <br />T <br />OR <br />ICC Technician's Name Randy Wilkerson <br />Expiration Date 5/26/2011 <br />ICC Installer's Name <br />Expiration Dale <br />Tank system work area <br />(Le 87 plp�V Sump, 91 Ink detector, uDc 1/2, etc.) Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved With conditions 12 Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />1 <br />Plan Reviewers Name� ljo�r Date <br />11) <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 <br />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 TOBECOME SUBJECT <br />TO WORKER*S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKEWS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicanrs Signature Compliance Officer nt. 1/20/2010 <br />BILLING INFORMATION: i <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 />EH230038 (revised 0201109) <br />1 <br />1/20/2010 <br />