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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 2 0 2013 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMIT/SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Greg Kaiser(209)401-2379 <br /> A <br /> C Facility Name Chevron Phone# <br /> I Address 6633 Pacific venue, Stockton, CA 95207 <br /> TCross Street Benjamin Holt <br /> Y Owner/Operator Edward Marszal a' Fbone# (916)488-3666 <br /> C Contractor Name Kaiser Commercial"petroleum Phone# (209) 887-2639 <br /> N <br /> T Contractor Address PO Box 1058, Lind6p, CA 95236 CA I is# 859535 Class A <br /> R Insurer A Brown&Brown Ins Svc 6f CA, PO Box 200, Stockton,,CA Work Comp# 1839765-17 <br /> c ICC Technician's Name <br /> T Greg Kaiser IC6 5252318, Service Tec/ Expiration Date 10/26/2017 <br /> R ICC Installer's Name Greg Kaiser ICC#5252318 Expiration Date 04/11/2019 <br /> Tank system work areaTank S e Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T Tank 3 regular unleaded 10,000 Regular Unleaded <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with condition ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N � <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WOVWH <br /> ANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL RTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FPERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS O " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THEHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECrTO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Authorized Contractor bate 9/1'$/2017 <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 Edward Marszal TITLE Owner PHONE# (916)488-3666 <br /> ADDRESS PO x 1 Ofi6, Carmichael, CA 95609 <br /> SIGNATURE '-*C, j DATE 9/18/2017 <br /> EH230038(revisedijOl11 <br /> i2) <br /> V <br /> 2 <br />