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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 /> XTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Greg Hohn 714-671 -3265 <br /> A <br /> C Facility Name Chevron Station Inc . # 208118 Phone # 209477-3699 <br /> I 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 <br /> o Wayne Perry , Inc . Phone # 714-826-0352 <br /> T Contractor Address 8281 Commonwealth Buena Park CA 90621 CA Lic # 300345 Class <br /> R A B C10 HAZ <br /> Insurer <br /> A Everest National Work Comp # CA1 0003737- 1 81 <br /> cICC 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. . I V (�Q, 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." 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 <br /> SIGNATURE ( / DATE J / <br /> 2 of 6 <br />