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SA N J O A Q U I N 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 /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Chevron 99840 Phone# <br /> I Address4344 E. Waterloo, Stockton CA 95215 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Chevron Products Company Phone#925 842-9002 <br /> C Contractor Name Wayne Perry Phone#657 262-8195 <br /> 0 <br /> N Contractor Address 8281 Commonwealth CA Lic# 300345 <br /> T Clas <br /> R <br /> A InsurerEverest National Inc Co. Work comp# CA 10003737221 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date <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 87 main 20K Petrolem <br /> A 91 5K Petrolem <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L k J(SA�tc <br /> tahment With Conditions) <br /> N <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI H SAN JO QUIN 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 G Title Permit Coordinator Date 12/5/23 <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 Becky Gallego TITLE Permit Coordinator PHONE#657 262-8195 <br /> ADDRESS 8281 Commonwealth Ave, Buena Park Ca 90621 <br /> SIGNATURE 6Q _ �Zg� DATE 12/5/23 <br /> 2of6 <br />