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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT 10 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name USA <br />Phone # 209-952-2213 <br />I <br />L <br />Address 10858 Trinity Parkway, Stockton CA 95219 <br />T <br />Cross Street Scott Creek Dr <br />Y <br />Owner/Operator Chevron USA <br />Phone # 925-287-7182 <br />C <br />Q <br />Contractor Name Service Station Systems, Inc. <br />y <br />Phone # 408-213-6038 <br />TN <br />Contractor Address <br />C 680 Quinn Avenue <br />CA Lic# 485184 Classg C61/D40 HAZ <br />RA <br />Insurer ICW Group <br />Work Comp # WPL502130700 <br />cICC <br />T <br />Technician's Name Randy Wilkerson <br />Expiration Date 5/19/2013 <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC M2, etc.) <br />Tank Size <br />Chemicals Stored Current! y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved _fi-Approved with conditions I!] Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Pian 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 AGENTS 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 <br />TO 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 />J �� L �L`�'L` <br />Appllcanrs Signature � fie Compliance Officer Dst, 5/2/2013 <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 />NAME Marty Weithman TITLE Compliance Officer PHONE # (408) 213-6038 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />SIGNATURE <br />EH230038 (revised 02!20/09) <br />1 <br />DATF 5/2/2013 <br />