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S A N JOAQUIN 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 /> A <br /> C Facility Name Chevron 307709 Phone # <br /> 1 Address 10858 Trintity Parkway <br /> I Cross Street <br /> T <br /> Y Owner/operator Chevron Products Company Phone # 657 262-8195 <br /> o Contractor Name Fastech Phone # 657 262-8195 <br /> T Contractor Address 7050 Village Dr Suite D CA Lic # 300345 Class <br /> A Insurer Ohio Casualty Insurance Com an Work comp # WC-6933416-00 <br /> T ICC Technician's Name James Fenner Expiration Date 12/19/26 <br /> Q ICC Installer's Name <br /> R Gabriel Venegas Expiration Date 06/16/25 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T Diesel 81< gasoline <br /> A 91 product 12k <br /> N <br /> K 87 product 20k gasoline <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 4/8/2025 <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 Till, Permit Specialist Dale 3/28/25 <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 TITLE PHONE # <br /> ADDRESS <br /> SIGNATURE DATE <br /> 2of6 <br />