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SAN O A (� (� � N Environmental Health Department <br />--F-1COL1NTI�YU`- <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERN41T TYPE BELOW. <br />❑ TANK RETROFIT 9 PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT LfCOLD START/EVR UPGRADE <br />F <br />EPA Site # CAL000408065 <br />Project Contact & Telephone # Rupi 209-914-8735 <br />AFacility <br />C <br />Name Shell Lodi <br />Phone # 209-914-8735 <br />I <br />Address 2420 W Turner Road, Lodi <br />L <br />TCross <br />Street Rutledge Drive <br />Y <br />Owner/Operator Tooley Oil Company <br />Phone # 916-972-1228 <br />C <br />0 <br />Contractor Name Town & Country Contractors, Inc <br />Phone # 916-636-9500 <br />T <br />Contractor Address 3206 Luyun Drive, Rancho Cordova <br />CA Lic # 238112 Class A,B,C36,D40,HAZ <br />A <br />Insurer ISU Atwood Agency <br />Work Comp # 921878217 <br />T <br />ICC Technician's Name Latham Zubillaga <br />Expiration Date 1/17/19 <br />°ICC <br />R <br />Installer's Name Same as above <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />T <br />Dispenser 1 & 2 <br />A <br />Dispenser 3 & 4 <br />N <br />K <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 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 />Anniirant'n Sianature Title_ 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 TITLE PHONE <br />ADDR <br />2 of 6 <br />DATE <br />