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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 /> 8 TANK RETROFIT 10 PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT B COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#Marty Weithman 408-213-6038 <br /> A <br /> Facility Name Shell Tesoro Phone# 209-369-3124 <br /> 1Address <br /> L 2448 Kettleman Lane, Lodi <br /> I Cross Street <br /> T Lower Sacramento <br /> Y Owner/Operator Tesoro Corporation Phone# 253-896-8809 <br /> C Contractor Name <br /> D Able Maintenance, Inc. Phone# 707-545-5522 <br /> N Contractor Address <br /> T 3224 Regional Parkway, Santa Rosa 95403 CA Lic# 312844 Class g A C10 HAZ <br /> R Insurer <br /> A Insurance Company of the West Work Comp# WPL500060302 <br /> T ICC Technician's Name <br /> Expiration Date <br /> DICC Installer's Name <br /> R Asa Heintz Expiration Date 5/12/2011 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e 87 piping sump,91 bak detector.UDC 1R,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ej Approved pproved with conditions [2 Disapproved <br /> L <br /> A (( <br /> (See Hchment With Conditions) <br /> N Plan Reviewers Name ( Axl ��_ <br /> 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 9 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! 7 <br /> Appllcanrs Signati �l,tiW tt cr tie Compliance Officer Dei 6/8/2011 <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 680Quinn Ave. San Jose, 95112 <br /> SIGNATURE—';'L L CC( i DATE 6/8/2011 <br /> EH230038(revised 02120109) <br /> 1 <br />