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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 e COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Marty Weithman 408-213-603 <br />C <br />1Address <br />Facility Name CheVroo Phone # 209-952-2213 <br />L <br />Trinity Park Wav <br />TCross <br />Street <br />Y <br />Owner/Operator Chevron USA <br />Phone # <br />o <br />contractor Name Service Station Systems <br />Phone # 408) 213-6038 <br />T <br />Contractor Address 680 Quinn Avenue <br />CA Lic# 485184 Class B C61040 HAZ <br />A <br />Insurer Insurance company of the West <br />work Comp # 3310020636081 <br />DICC <br />T <br />Technician's Name John Talbott <br />Expiration Date 2/26/2011 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 Wk tletecloi, UDC 72, 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 IJ Disapproved <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name V 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 <br />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.' CONTRACTORS 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 WORKERS <br />OF CALIFORNIA.' COMPENSATION LAWS <br />a <br />ApplkanraSignatura.• uompllance urrlcer <br />9/18/09 <br />D.L. <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 PHONED (408) 213-6038 <br />680 Quinn Avenue San Jose, CA 95112 <br />SIGNATURE I�7 C-Lat ,.� L DATE 9/18/09 <br />EH230038 (revised 02/20/09) <br />