Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT 10 PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT e COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />D <br />Facility Name Shell Tesoro Phone # 209-369-1525 <br />1 <br />L <br />Address 33 N Cherokee Lane, Lodi CA 95240 <br />I <br />T <br />Cross Street Elm St <br />Y <br />Owner/Operator Tesoro Corporation <br />Phone # 253-896-8700 <br />cContractor <br />o <br />Name y <br />Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic # 485184 C18SSB C61/D40 HAZ <br />A <br />Insurer ICW <br />Work Comp # WPL502130701 <br />cICC <br />T <br />Technician's Name Randy Wilkerson <br />Expiration Date 5/2/2015 <br />DICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 Ink detector, UDC 1n, etc.) <br />Tank Size Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />N <br />K <br />r v <br />77 <br />P <br />Approved Approved with conditions In Disapproved <br />L(S <br />A <br />N <br />hment With Conditions) <br />A� — _ W <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br />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 CALIFORNIA.' <br />r� <br />AppllcanrsSignature y'L CL,( t L CC,� ComplianceOfficer Dace 1/27/14 <br />BILLING INFORMATION: <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 <br />TE 1/27/2014 <br />