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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone ' (209) 468 - 3420 Fax : (209) 468- 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 1 £30 DAYS FROM THE APPROVAL DATE. INDICATE. PERMIT TYPE BELOW; <br /> ❑ TANK RETROFIT [] PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT NCOLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Angel Rodriguez 916-373 - 1165 <br /> A <br /> O Facility Name Tesoro 468221 Phone # <br /> I Address <br /> L 2705 Country Club Blvd. Stockton CA 95204 <br /> Cross Street <br /> T <br /> Y Owner/Operator Tesoro Phone # <br /> c Contractor Name Walton Engineering, Inc. Phone # 916-373 - 1165 <br /> 0 <br /> N Contractor Address P . O , Box 1025 West Sacramento CA 95691 CA Lic # 617238 Class AB HAZ <br /> T <br /> R <br /> A Insurer State Compensation Insurance Fund Work Comp # 9113339-2017 <br /> ICC Technician's Name Michael Raymond - 8156309 Expiration Date 3-282020 <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (is. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> I <br /> A Re lace Replace 87 & 91 SC & DT . <br /> N Replace Diesel DT only . <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A u1 J <br /> N Plan Reviewers Name ate ' ys o Date 0 � 1 ( Z l o <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> 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 <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature 49.IZ,12Title I Date q <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 �' I + � — TITLE f PHONE # <br /> ADDRESS PO' <br /> SIGNATURE f DATE <br /> EH230038 (revised 7-26-2016) 2 <br />