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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 # Emily Crain 916- 371 -2380 <br /> A <br /> G Facility Name Lodi Chevron Phone # 30 <br /> I <br /> L Address 601 E Kettleman Lane , Lodi <br /> T Cross Street Cherokee Lane <br /> Y Owner/Operator V// !►ii�G'/� 01NN4 U Phone # f 30 �3 ��-� 3S"� <br /> C Contractor Name BZ Maintenance Phone # 916- 371 -2380 <br /> 0 <br /> T Contractor Address PO Box 933 , W Sac 95691 CA Lic # See attached Class <br /> A Insurer see attached Work Comp # <br /> T ICC Technician ' s Name see attached Expiration Date <br /> 0ICC Installer' s Name <br /> R 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- 1 12032 UNL <br /> A 87-2 12032 UNL <br /> N <br /> K 91 9684 UNL <br /> DSL DSL <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A i I <br /> N Plan Reviewers Name � 0n <br /> / 1 `b e r �� � f ' & Z, L <br /> Date © � t � G S Z l <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 W WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. " <br /> h / <br /> Applicant's Signature Title ©�/ v �r 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. <br /> NAME5;Vj �'////' /'/�/V� � TITLE OW PHONE # <br /> ADDRESS O 76 /6� A' j/ /!� ; ' 75 <br /> c, y <br /> SIGNATURE DATE <br /> EH230038 (revised 12- 11 - 15) 2 <br />