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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY RECEIVED 1868 E. Hazelton Ave., Stockton, California 95205 Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 2 0 2017 APPLICATION FOR UNDERGROUND STORAGE TANK EWIRONMENTAL HEALTH RETROFIT OR PIPING REPAIR PERMIT PERMIT/SERVICES THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE F EPA Site# Project Contact&Telephone# Greg Kaiser(209)401-2379 A C Facility Name Chevron Phone# I Address 6633 Pacific Avenue, Stockton, CA 95207 L TCross Street Benjamin Holt Y Owner/Operator Edward Marszal Phone# (916)488-3666 o Contractor Name Kaiser Commercial Petroleum Phone# (209)887-2639 .T Contractor Address PO Box 1058, Linden, CA 95236 CA Lic# 859535 Class A R Insurer A Brown&Brown Ins Svc of CA, PO Box 200, Stockton, CA Work Comp# 1839765-17 T ICC Technician's Name Greg Kaiser ICC#5252318, Service Tech Expiration Date 10/26/2017 R ICC Installer's Name Greg Kaiser ICC#5252318 Expiration Date 04/11/2019 Tank system work area Tank Size Chemicals Std Current) Date UST Stored(i.e.87 piping sump,91 leak detector,UDC 112,etc.) y Installed T Tank 3 regular unleaded 10,000 Regular Unleaded A N K P ❑ Approved ❑ Approved with conditions ❑ Disapproved L A (See Attachment With Conditions) N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Applicant's Signature Title Authorized Contractor Date 9/18/2017 BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Edward Marszal TITLE Owner PHONE# (916)488-3666 ADDRESS P0!3qyd1q9q, Carmichael, CA 95609 SIGNATURE DATE 9/18/2017 EH230038(revised 10 / 2) 2