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Ir <br /> REO&V@&AL HEALTH DEPARTMENT <br /> - SAN JOAQUIN COUNTY RECEIVED <br /> 498 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 SEP 2 0 2017 <br /> ENVIRONMENTAL HEALTH <br /> nFPAR*WWION FOR UNDERGROUND STORAGE TANK EW1R0NmE1qTALHEALT1i <br /> RETROFIT OR PIPING REPAIR PERMIT PEIRMITISERIACES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone 9 Greg Kaiser(209)401-2379 <br /> A <br /> C Facility Name \Chevron Phone# <br /> L Address —3 Pacific Avenue,Stockton,CA 95207 <br /> I cross street "n min Holt <br /> T <br /> Y Owner/OperatorEdwar arszal'!�MPhonQ4( -3r,66 <br /> c Contractor Name (916)488 <br /> 0 Kalser al Petroleum Phone# (209)887-2639 <br /> N Contractor Address PO Box 105-81 <br /> T Linden,CA 95236 CA tujc# 859535 Class A <br /> R Insurer <br /> A Brown&Brown li*Svc of CA,PO Box 200,Stockton,(;W I Work Comp# 1839765-17 <br /> T <br /> 0 ICC; ecrilclan's Name <br /> T hGreg Kaiser ICC#5252318,Service Ted/ Expiration Date 10/26J2017 <br /> 0 <br /> R ICC Installer's Name Greg Kaiser CC#5252318 Expiration Date 04/11/2019 <br /> Tank system work area Date UST <br /> OA 97 opsystem1took 4eftW.UDC I12,w-) �Emk Size hemicals Stored Currently Installed <br /> T Tank 3 regular unleaded 1 000 Regular Unleaded <br /> A <br /> N <br /> K <br /> A <br /> 13 El Approved ❑ Approved conditions ❑ Disapproved <br /> L Be Attachment Conditions) <br /> A <br /> N <br /> Plan Reviewers NameM A 0(11 Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR E WITH SAN JOAQUIN CES,STATE LAVA,AND RULES AND REGULATIONS OF SAN <br /> C E STATE <br /> C <br /> CES, <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DE TMENT.OWNER OR LICENSED I IGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSON IN SUCH A MANNER AS To BECOME SUBJECT To <br /> WORKEWS COMPENSATION LA CONTRACTOR'S HIRING OR SUBCONT NG SIGNATURE CERTIFIES THE FOLLOWNG: 'I CERTIFY <br /> THAT IN THE PERFORMANCE Wo FOR WHICH THIS PERMIT IS ISSUED,I SHALL Elmp ERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORMW EM <br /> Lo <br /> [AWkwit Sigroture T�z CIO <br /> Authorized Contracloi _Date 9/18/2017 <br /> BILLING INFORMATION: <br /> Indicate the Lai party to be billed for additional EHD staff time expanded beyond I payment coverage per t <br /> res!"o be ant 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 data below, <br /> NAME Edward Marsmi ..TITLE OWner PHONE 9 <br /> (916)488-3666 <br /> ADDRESS PO 1 16,Carmichael, CA 95609 <br /> SIGNATUIR-7EJ. AA C <br /> DATE 9/18/2017 <br /> El-1230= (reel8(r 1 12) <br /> 2 <br />