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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 START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Angel Rodriguez 916-3734165 <br /> A <br /> C Facility Name Tesoro #68153 Phone # <br /> I Address <br /> L 2448 W. Kettleman Lodi CA 95242 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Tesoro Phone # <br /> C Contractor Name Walton Engineering, Inc. <br /> o Phone # 916- 373 - 1165 <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 /> cT 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 Phil-Tite SC in a sump . ( Like for Like) <br /> A <br /> N - Replace all 3 drop tubes Phil-Tite . <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A ,�� // rev <br /> N Plan Reviewers Name '"� . � � �'� n�40 r S •(k`Vu OL 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." ONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE WORK FOR WHI THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title 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. n <br /> NAME A l L(-1C"rt', � �J C� � l CJ -'� TITLE ' " r Ci c PHONE # � - 3 73 <br /> ADDRESS V' . L/ . � O © L (_J C. S + Si;, f ^ G ,►y�L'!�z �-O C ¢ S l <br /> SIGNATURE DATE <br /> EH230038 (revised 7-26-2016) 2 <br />