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REC VED <br /> c�CT06!NYIRONMENTALLT <br /> . A J UI COUNTY <br /> ENVIRONMENTAL /ALT . E. H elton Ave., Stockton, Callfomla 95205 RECEIVED <br /> DEpARTMENT Telephone:(209)468-3420 Fax: (209)466-3433 <br /> EP 2 0 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK EKIRONmEWALN <br /> MLTN <br /> RETROFIT OR PIPING REPAIR PERMIT pE )TSEWCES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> ❑ <br /> TANK RETROFIT ❑PIPING A RoFiT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Sim# PrajeetCantata&T # <br /> G aer 209 401-2379 <br /> C Facility Name Chevron <br /> I Phone# <br /> L 6633 Pacific Avenue,Stockton,CA 85207 <br /> T Cross;SBenjamin Holt <br /> Yl/ rator Edward Marazed Phon�# (qj <br /> 6 488- <br /> ° Ccx} r e I P sum Phan <br /> T Or PO ION,Linden,CA 95236 209 887-21339 <br /> R CA LIC# 859535 Class A <br /> A Insurer Brown&Brown Ins Svc of CA PO Box 200,Stockton,CAWOrkCOmP# 1839765-17 <br /> Tc tCC-Techrftm's Al e <br /> s G I252318,Service <br /> T Expiration <br /> on f 01 <br /> 7 ICC tns s G ICC#8252318 Expiration Date 11/2019 <br /> Tank <br /> Pe7 ,91 ,uoc uTank Size C cats Stored <br /> Date UST <br /> Installed <br /> urU <br /> T T 3 e ular unleaded 10,000 <br /> A ed <br /> N <br /> K <br /> P <br /> ® ed with conditions ❑ <br /> A (See AttachrImt Vft CondWan) Disapproved <br /> NPlan Reviewers Name <br /> nate__ <br /> PLICANT MUST PERFORMALL WORK IN ACCORMqjCE WTH SAN JOAQUIN COUNTY CES STATE RULES <br /> tRN TY, N AL TH AR ER OR LIC O TS NATURE TIFIES THE AND REauca Spry <br /> E PER CE OF THE CH PERMIT IS ED,t NOT EMPLOY IN p "1 CERTIFY THAT IN <br /> KER'S'C CT HIRING OR SUSC AS TO BECOME SUBJECT TO <br /> T IN THE PERF E CERTIFIES THE . q Y <br /> CALIFORNW CH THIS MITIS ISSUED,I t EMPLOY PERSONS SUBJECT TO 'S COMPENSATION LA <br /> WS <br /> TAIm Authorized Con or Df, 9/18/2017 <br /> BILLING INFO TION: <br /> Indicate the ible party to be filed for additional END steff Urne,expanded beyond mdt Payment coverage per <br /> the Party designated below Is dWerent applicant e.g. ownerr,, the party must acknowledgek if <br /> responsibility for ng by signature and date <br /> n below. Ns <br /> NAMI Edward Ma <br /> TI7LE PH0NE#__,(916}48 <br /> ADID)RESWS PO x 1 Carmichael, CA 95609 <br /> SIGRIATURE <br /> PATE 9/18/2017 <br /> 8 E 2) <br /> 2 <br /> i <br />