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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 RETROFITE�PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Eric Janzen (707)293-2986 <br /> A <br /> C Facility Name Chevron#98264 Phone#209-836-9422 <br /> � Address 3775 Tracy Blvd., Tracy CA 95376 <br /> 1 Cross Street Interstate-205 <br /> T <br /> Y Owner/Operator Chevron USA Phone# <br /> c Contractor Name Able Maintenance, Inc. Phone#707 293-2986 <br /> 0 <br /> T Contractor Address 3224 Regional Parkway, Santa Rosa, 95403 CA Lic# 312844 Class A. B,C10, HAZ <br /> R <br /> Insurer Insurance Company of the West Work Comp#WPL500060303 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Mike Trejo Expiration Date4/13/2013 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> cto <br /> (i.e.87 piping sump,91 leak deter,UM 12,etc.) Installed <br /> T 98264 Premium(91) 12,000 gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Sttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date aZO 1 Z <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 <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 WO FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicant's Sigfur, <br /> �— Tltle ' Date1A 6A 2,eg, <br /> BILLING INFORMATION: <br /> Indicate the responsible party t e 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 <br /> Eric Janzen TITLE Code Compliance Officer PHONE#707-293-2986 <br /> 3224 Regional Parkway, Santa Rosa CA 95403 <br /> ADDRESS rrss <br /> SIGNATU DATE ld /TiCJ <br /> EH2300 8(revi 02/20/ <br /> 1 <br />