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• • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTYLi <br /> 1868 E. Hazelton Ave., Stockton, California 95205 Fit C`w `1% F c: " <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 JAN 2 6 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ] UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# CAR000142463 Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C Facility Name Tesoro Shell#68151 Phone# 210-626-6153 <br /> 1 Address <br /> L 35 N.Cherokee Lane Lodi CA 95240 <br /> TCross Street <br /> Y Owner/Operator Tesoro Phone# 210-626-6153 <br /> C Contractor Name Walton Engineering,Inc. <br /> o Phone# 916-373-1165 <br /> N <br /> T Contractor Address P.O.Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp# 9113339-2017 <br /> C r ICC Technician's Name David Delgado-5246959 Expiration Date <br /> 12-29-2019 <br /> R ICC Installer's Name David Delgado-5246959 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T Repair VaIDor Pipe Leak <br /> A <br /> N <br /> K <br /> P ❑ Approved VlApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A l) �I,!_ <br /> N Plan Reviewers Name _ �$�� ��YG`�G""' Date p jo,*�/x7- <br /> Plan <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: "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 TO <br /> WORKER'S COMPENSATION LAWSOF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE THE WORK FOR WHI H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." r� <br /> Applicant's Signature Title r•' .y, c_t Date I ZSR 1 S <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 M\iC �EI t^%C.a� �O�� TITLE �^FS��¢.� PHONE# <br /> ADDRESS (,4 9569 <br /> SIGNATURE DATE 1/2V 1 PI <br /> EH230038(revised 7-26-2016) 2 <br />