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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 D PIPING REPAIR/RETROFIT a UDC REPAIRIRETROFIT B COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact 8 Telephone # Marty Weithman 408-213-6038 <br />C <br />Facility Name Shell Tesoro <br />Phone # 209-727-0823 <br />1 <br />L <br />Address 2448 W Kettleman Lane Lodi CA 95242 <br />1 <br />T <br />Cross Street Lower Sacramento <br />Y <br />Owner/Operator Tesoro Corporation <br />Phone # 253-896-8700 <br />C <br />Contractor Name Service Station Systems, Inc. <br />Phone # 408-213-6038 <br />N <br />Contractor Address 680 Quinn Avenue <br />CA Lic # 485184 Class[3 <br />B C61/D40 HAZ <br />R <br />A <br />Insurer ICW <br />Work Comp # WPL502130701 <br />cICC <br />T <br />Technician's Name Randy Wilkerson <br />Expiration Date <br />5258560 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e 87 piping sump, 91 leak detector, UDC 1/t, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with conditions Disapproved <br />L <br />A <br />(2e Attachment With Conditions) <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: '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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicant's Signature % �_jLc.f. �;ye Compliance Officer Date 1/30/2014 <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 <br />680 Quinn Ave. San Jose, 95112 <br />PHONE 4 (408) 213-6038 <br />SIGNATURE 'l''��1��(✓ % L-�1i1�L DATE 1/30/2014 <br />EH230038 (revised 02/20109) <br />1 <br />