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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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/ RETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Angel Rodriguez 916-373 - 1165 <br /> A Phone # <br /> Facility Name Tesoro #68150 <br /> I Address 13975 E . H 88 Lockeford 95237 <br /> L <br /> 1 Cross Street <br /> T Phone # <br /> Y Owner/Operator Tesoro <br /> c Phone # 916 -373 - 1165 <br /> QContractor Name Walton Engineering, Inc . <br /> Class AB HAZ <br /> N Contractor Address P . O . Box 1025 West Sacramento CA 95691 CA Lic # 617238 <br /> T Work Comp # 9113339-2019 <br /> R Insurer State Compensation Insurance Fund <br /> A Expiration Date 12-29 -2019 <br /> C ICC Technician ' s Name David Delgado - 5246959 <br /> T Expiration Date 9 -24-2020 <br /> Q ICC Installer's Name David Delgado - 5246959 <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) <br /> T <br /> A Re lace diesel dro tube . <br /> N <br /> K <br /> P El Approved <br /> pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A � 12 <br /> N <br /> Date <br /> Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL WORK ACC 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 /> L EMPLOY ANY <br /> AS TO BECOME <br /> THE PERFRMANCE WORKER'S COMPENSOF THE WORK FOR WHICH THIATION LAWS OF CALI ORN AS' ISSUED ; <br /> RIACTOR S HIR NGOR SPERSON MANNERIN SUCH A <br /> UBCONTRACTINGS GNATURE CERTIFIESTHE FOLL WINGSUBJECT CERTIFOY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER�COMPENSATION <br /> OF CALIFORNIA" LAWS <br /> nn s vL/ J 4 <br /> Title <br /> Applicant's Signature Y� <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 /> responsi olity for the billingi atCre and do below, 16 <br /> _ �/ 3 _ 0 / <br /> NAME <br /> TITLEPAA PHONE # (7 1� <br /> ADDRESS Pool <br /> DATE � � � y � I <br /> SIGNATURE <br /> EH230038 (revised 7-26-2016) 2 <br />