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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 18 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TANN <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> PfTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#A&S Engineering Ahmad Ghaderi/661-250-9300 <br /> A <br /> C Facility Name Phone# 661-250-9300 <br /> 1 Address 401 West Kettleman, Lodi, CA 95240 <br /> L <br /> TCross Street South Lee Ave <br /> Y Owner/Operator Tesoro Refining &Marketing Company LLC Phone#210-626-6224 <br /> C Contractor Name Fuel Pros Inc. Phone# 909-614-1379 <br /> 0 <br /> 1" Contractor Address 14774 Central Ave, Chino, CA 91710 CA Lic# 269354 Class A, C36, B <br /> A Insurer Midwest Employers Casualty Company work Comp# BNUWC0133329 <br /> C ICC Technician's Name Expiration Date <br /> T Raul Vasquez p� 12/9/2017 <br /> R ICC Installer's Name Raul Vasquez Expiration Date 3/10/2018 <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 Existing to Remain <br /> A <br /> N <br /> K <br /> P ❑ Approved �JApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name h 7ZM Date Kol ha <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO ANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH D ARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHIC HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALI RNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE W FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /� ,�. c r' / <br /> Applicant's Signature Title WOWW �Z `el �t Date L� ►J !ZZ0 �• <br /> BILLING INFORMATION: <br /> Indicate the responsiblparty 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 A&S Engineering TITLE Agent for Tesoro PHONE# 661-250-9300 <br /> ADDRESS 28405 Sand Canyon Road, Canyon Country, CA 91387 <br /> SIGNATURE DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />