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Al�M' "", -- ---- - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209)4683433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMI T TYPE BELOW. <br /> '/TANKRETROFIT 0 PIPING REPAIRIRETROFIT [JUDC REPAIRIRETROFIT LI COLD STARTIEVR UPGRADE <br /> F EPA Site Project Contact&Telephone 0 A&8 Engineering, Robert Velasco <br /> A <br /> C Facility Name Tesoro USA 68222 hone 210-626-6224 <br /> L Address 2132 Mariposa Road,Stockton CA 95205 <br /> I Cross T r as Street Farmington Road <br /> Y' Owner/Operator Tesoro Refining&Marketing Company LLC Phone 0 210-626-6224 <br /> Contractor Name, Gettler Ryan Inc. phone# 92s-5m.7555 <br /> 0 <br /> N T <br /> Contractor Address 68a5 Sierra Ct.Suite*G'7,D flnCA945�68 CA 220793 Class B,C-61, D-40 C-10, <br /> R Insurer Platte River Insurance Company Work Comp# 41302369 Haz. <br /> A <br /> cExpiration Date <br /> T ICC Tacturtician's Name <br /> 0 <br /> M Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> IT0,87 Pk*9 e p,91 Ink ft..W.00012,01c) Installed <br /> T Fill&Turbine Sumps Existing to remain 87 Prod.LIST Unleaded Fuel xlsfirigl to remain <br /> A ill&Turbine Sumps xisting to remain 89 Prod.LIST Unleaded Fuel Existing to remain <br /> N <br /> K III&Turbine Sumps Existing to remain 91 Prod. UST Unleaded Fuel Existing to remain <br /> Fill&Turbine Sumps Exlslfing to remain Diesel Prod.LIST Unleaded FuEd x1sting to remain <br /> 7-== <br /> P Approved / Approved with conditions Disapproved <br /> I a <br /> L (Se Xachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> I <br /> ANEAPPLICANT MUST ALL K ACCC ANCE WITH <br /> THGANJOA <br /> QU <br /> IN <br /> COUNTY <br /> ORDINANCES, <br /> RDINANCES <br /> ,STATE LAWS,A <br /> N <br /> D RULES <br /> AN <br /> D R <br /> E <br /> GULATGIONS OF <br /> S <br /> AaUoNTY-E 'R0TALHULHANTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE I CERTIFY THAT i <br /> Na POP RMA C OF RK FOR� 1PMITISU01SHALLNOTEMLoANY PERSON INSUCRA EMaGoME6ua�CTTo�RK <br /> WORKER'S LAWS OF CFN CONTRACTOR'S <br /> ONTRACTOR SORINGORSUBCONTRACTING SIGNATURE <br /> CERTIFIES <br /> THE FOLL 1CERT�FY <br /> THAT <br /> IMTH!PEnVORMANC5OrTHE WO OR IC8 THIS <br /> PERMITIs ISSUED, <br /> 1 SHALL <br /> EMPLOY <br /> PERSONS <br /> SUBJECT <br /> To RKEa COMPENSATIONS LA <br /> 0CAL'FO A <br /> Ap �r� TB. Agent for TOSOM Dt. I1/2012r1 <br /> I6 <br /> BILLING INFORMATION: <br /> Indicate the responsible pX to be billed for additional 51-11)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 A&S Enginee&W, Robert Velasco TITLE Agent for Tesoro MONE* 661-250-9300 <br /> ADDRESS 28406 Sand Canyon Road,Suit 9/" Canyon Country CA 91387 <br /> SIGNATURE DATE 11120/2015 <br /> EH1230038(revised 07-17-2014) <br /> 2 <br />