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I <br /> RW&,V#" SrAL HEALTH <br /> SAN JOAQUIN COUNTY <br /> 8 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> Telephone: (209)468-3420 Fax: (209)468-3433 SEP 2 0 2017 <br /> ENVIRONMENTAL HEALTH <br /> DFDAQ k TION FOR UNDERGROUND STORAGE TANK EWIRONMENTALH TH <br /> RETROFIT OR PIPING REPAIR PERMIT PE IT/SERVlCES <br /> THIS PEROT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> 0 TANK RETROFIT 0 PIP114G REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Pr ' Contact 8 Telephone# Greg KWser 209 401-2379 <br /> A <br /> C FacilityName Chevron Phor� <br /> 1L Address GM Pacific Avenue,Stockton,CA 95207 <br /> 1 cross street Bianiamin Hof# <br /> T <br /> V Owner/ for Edward Marsizall Phone# 918 488-3866 <br /> O Contractor ao Kaiser el Petroleum <br /> (209)887-2639 <br /> N <br /> T Contractor Address PO Box 1058,Lindell,CA 95236 CA Lk;# 859535 Class A <br /> A Insurer Brown&Bmwn Irks Svc of CA,PO Box 200,Stockton,CA Co mP# 1839765-17 <br /> Y ICC Technician's Name G Kaiser IC 252318,Se T Expiration Date 10/26/2017 <br /> R ICC Installer's N Greg 1CC#5252318 Expiration Date 04/11/2019 <br /> Date UST <br /> OA V 'rank*stem work area 91 kwk"wW.UDC M l T Size Chemfc Is S Currently installed <br /> T <br /> Tank 3 ENular unleaded 10,000 R ular Unleaded <br /> A <br /> N <br /> K <br /> P ❑ Approved DApproved with conditions ❑ Disapproved <br /> L (See Attachment Vft Conditions) <br /> A <br /> N Plan Reviewers Name <br /> D' <br /> APPLICANT MUST PERFORM ALL wM IN ACCORDANCE WITH SAN JOA=tN COUNTY ORDINANCES,STATE LAM,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT.OwNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE F "I CERTIFY THAT IN <br /> E PERFORMANCE OF THE wORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> wORKFR'S COMPENSATION LA OF ORNVW CTOR'S HIRING OR SUBCONTRACTING$*NATURE CERTIFIES THE FOLLt. W CERTIFY <br /> T IN THE PERP E H WO FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKEMS COMPENSATION LAWS <br /> OF NIA" <br /> Tiff. Authorized Contra r 9d1812017 <br /> BILLING INFORMATION: <br /> Indicate theparty to be tilled for additlortall EHD s 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 Marazal TITLE Owner <br /> PHONE#__(916)488 <br /> ADDR <br /> ESS <br /> PO x 19%,Carm ael,CA 95608 <br /> SIGNATtJR ' DATE 9/18t2017 <br /> 4 <br /> 4 12) <br /> 2 <br /> i <br />