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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468 - 3420 Fax : (209 ) 468 -3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # MERLIN BOWEN 925 . 551 . 7555 <br /> � <br /> Facility Name CHEVRON SS#210997 Phone # <br /> I <br /> L Address 1442 COLONY ROAD , RIPON <br /> T Cross Street HWY , 99 <br /> Y Owner/Operator CHEVRON PRODUCTS COMPANY Phone # 925 , 842 , 9002 <br /> C Contractor Name Wayne Perry Inc Phone # 916 . 646 . 9680 <br /> O <br /> N Contractor Address 30 Main Street, Suite 5 , Sacramento , CA 95838 CA Lic # 300345 Class A/B/C61 -D40/CIO <br /> T <br /> A Insurer Everest National Insurance Company Work Comp # CA1 0003737- 1 81 <br /> T ICC Technician 's Name Donald W Baughn Expiration Date 2/25/2020 <br /> R ICC Installer' s Name Donald W Baughn Expiration Date 4/ 12/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T SUPREME UNLEADED-91 15 , 000 GASOLINE <br /> A REGULAR UNLEADED-87 20 , 000 GASOLINE <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Attachment With Conditions) <br /> A /N Plan Reviewers Name414 y— — 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 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 TO <br /> 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 /> Applicant's Signature / ' Title AGENT FOR OWNER 10/ 15/2019 <br /> Date <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 Liddy McKenzie TITLE Project Manager PHONE # 925 . 551 . 7555 <br /> ADDRESS 6805 SIERRA CT , SUITE G , DUBLIN , 94568 <br /> SIGNATURE , DATE 10/ 15/2019 <br /> EH230038 (revised 07-46-2014) <br /> 2 <br />