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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 REPAIRIRETROFIT ® UDC REPAIR/RETROFIT a COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Facility Name Shell Tesoro Phone# 209-369-3124 <br /> I Address <br /> L 2448 W Kettleman Lane, Lodi CA 95242 <br /> I Cross Street Lower Sacramento <br /> T <br /> Y Owner/Operator Tesoro Refining and Marketing Copany Phone# <br /> 253-896-8700 <br /> C Contractor Name <br /> Q Service Station Systems, Inc. Phone# 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> R A Insurer ICW Group <br /> Work Comp# WPL502130700 <br /> cICC Technician's Name <br /> T Jeremy Findley Expiration Date 6/1/2013 <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e 87 piping sump,91 leak detector,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved U,Approved with conditions [2 Disapproved <br /> A /4ttachment With Conditions) n <br /> N <br /> Plan Reviewers Name 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: '1 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.' �1 J <br /> AppllcartfsSignature { ( �l /h C tc ?Ine Compliance Officer Date 8/27/12 <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 PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. Sant Jose, 95112 <br /> SIGNATURE CL-t�Gtt- tit DATE 8/27/12 <br /> EH230036(revised 02/20/09) <br /> 1 <br />