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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 B UDC REPAIRIRETROFIT B COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />A <br />c <br />Facility Name Chevron USA <br />Phone # 209-952-2213 <br />1 <br />L <br />Address y <br />10858 Trinity Parkway Stockton CA 95219 <br />1 <br />T <br />Cross Street Scott Creek Dr. <br />Y <br />Owner/Operator Chevron US <br />Phone # 209-952-2213 <br />fl <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />T <br />Contractor Address 680 Quinn Avenue <br />485184 Class <br />CA Lic# B C61/D40 HAZ <br />RA <br />Insurer Cypress Insurance Company <br />Work Comp # 3310020636091 <br />T <br />ICC Technician's Name Matt Estabrook <br />Expiration Date 5/28/2011 <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e e7 piping sump, 91 leak detector, UOC 12, 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 Approved with conditions Disapproved <br />L <br />A <br />> (See Attachment With Conditions) <br />N <br />� J <br />Pian Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WOKIK 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 <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 />ApplicantsSignatum _ Vl,LILC LLilL ,*. Compliance Officer Det, 11/18/09 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff lime 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 ft y �(�V,; . 4•_f,4 DATE 11/18/09 <br />EH230038 (revised 02/20109) <br />1 <br />