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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209) 46 &3420 Fax : (209) 468 -3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <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 # Angel Rodriguez 916-373 - 1165 <br /> A <br /> C Facility Name Tesoro #68152 Phone # <br /> I Address <br /> L 401 W . Kettleman Lodi CA 95240 <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 <br /> T Contractor Address P . O . Box 1025 West Sacramento CA 95691 CA Lic # 617238 Class AB HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp # 9113339-2017 <br /> C T ICC Technician 's Name David Delgado .- 5246959 Expiration Date <br /> 12-29 -2019 <br /> R ICC Installer's Name David Delgado - 5246959 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T Replace direct-bu 91 spill container. <br /> A <br /> N — Replace 91 drop tube . <br /> K <br /> P ❑ Approved X Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 COMPENSATION LAWS OF CALIFORNIA." C NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF E WORK FOR WHIC HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title �r C Date <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. �I / 2 <br /> NAME ll v� I C �rnQ� � w e I v TITLE 1 I e. s PHONE # 16 ` 3 J J � I S2 <br /> ADDRESS � ' v • (30 )( I G2 (j C S c. cmc . e It C3C ry S� 1 <br /> SIGNATURE DATE <br /> EH230038 (revised 7-26-2016) 2 <br />