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_ ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> /FFo 1868 E . Hazelton Ave . , Stockton , California 95205,., <br /> Telephone : 209 468- - ' <br /> p ( ) 3420 Fax : 209 468 3433= � <br /> �0APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMITIFOF <br /> ,.. <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Kristin Nappen / 916 - 373 - 1165 <br /> A Facility Name Tesoro #68221 Phone # <br /> 209 -939 - 9295 <br /> L Address 2705 Country Club Blvd, Stockton CA <br /> TCross Street <br /> Y Owner/Operator Tesoro Phone # 209 - 939 - 9295 <br /> o Contractor Name Walton Engineering, Inc . Phone # 916 - 373 - 1165 <br /> N Contractor Address CA Lic # Class <br /> T 3900 Commerce Dr. West Sacramento CA 617238 AB HAZ <br /> A Insurer See Attached Work Comp # <br /> cICC Technician 's Name <br /> T See Attached Expiration Date <br /> QICC Installer's Name <br /> R See Attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) y <br /> Installed <br /> T SB 989 Repairs <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> N <br /> A Plan Reviewers Name 1 Date_ <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 COMPENSATIO LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR E OF THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS <br /> OF CALIFORNIA." Q <br /> Applicant's Signat Tide Construction Manager Date..if 42r / <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 Kr1St111 NappenTITLE Construction Manager PHONE # 916 - 373 - 1165 <br /> ADDRESSP , 01025 , V&Af Sacramento CA 95691 <br /> SIGNATURE DATE mg <br /> EH230038 (revised 7-26-2016) 2 <br />