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SANJOAQUIN Environmental Health Department <br /> -COUNTY- <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 /> A F EPA Site# Project Contact&Telephone#Greg Hohn 714-671-3265 <br /> C Facility Name Chevron Station Inc.#208118 Phone#209-477-3699 <br /> 1 Address 3355 E. Hammer Road, Stockton, CA 95212 <br /> L <br /> TCross Street Holman Road <br /> Y Owner/Operator Chevron Products Company Phone# 925-842-9002 <br /> C Contractor Name Wayne Perry, Inc. Phone# 714-826-0352 <br /> T Contractor Address 8281 Commonwealth Buena Park CA 90621 CA Lic#300345 ClassA B C10 HAZ <br /> R <br /> A Insurer Everest National Work Comp# CA10003737-181 <br /> C ICC Technician's Name <br /> T Donald W. Baughn Expiration Date 2/25/20 <br /> oICC Installer's Name <br /> R 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 Installed <br /> T 87 direct-bury fill spill bucket 20,000 gal. 87 unleaded <br /> A 91 direct-bury fill spill bucket 15,000 gal. 91 unleaded <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S e Attachment With Conditions) <br /> A �n <br /> N Plan Reviewers Name �.1 V I M-W Date 7: n: <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 Title Permit Agent Date <br /> BILLING INFORMATION.- <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Greg Hohn TITLE Permit Agent PHONE# 714-671-3265 <br /> ADDRESS PO BOX 2292, Brea, CA 92822 r� <br /> SIGNATURE _ DATE I I -J <br /> 2 of 6 <br />