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AVOR 13 2017 <br />ENVIRONMENTAL L IT,E"'ESLTH <br />SAN JOAQUIN COl1 T <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 TA IRONMENTAL HEALTH <br />RETROFIT PIPING REPAIR PERMIT DEPARTMENT <br />THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />STANK RETROFIT ❑ PIPING REPAIR/RETROFIT r7 UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone 0 A & S Englnaertng Ahmad Ghaderl 1661.250.8300 <br />C <br />Facility Name Phone 9 661-25D-9300 <br />I <br />L <br />Address 401 West Kettleman, Lodi, CA 95240 <br />I <br />T <br />Cross Street South Lee Ave <br />Y <br />Owner/Operator Tesoro Refining & Marks Company LLC <br />Phone s 210-626-6224 <br />G <br />0 <br />Contractor Name Fuel Pros Inc. <br />Phone # 909-614-1379 <br />T <br />Contractor Address 14774 Central Ave, Chino, CA 91710 <br />Llo# 269364 Class A, C36, 6 <br />A <br />Insurer Midwest Employers Casualty Company <br />Work Comp # BNUWC0133329 <br />T <br />ICC Techniclan's Name Raul Vas uez <br />Expiration Date 12/9/2017 <br />R <br />ICC Installers Name Raul Vasquez <br />Expiration Date 3/10/2018 <br />Tank system work area Tank Size <br />(1.®, srp41ng sump, 61 lookdmcta, UDO112. aim) <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />Existing to Remain <br />A <br />N <br />K <br />P <br />Approved Approved with conditione ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />? ` <br />Plan Reviewers Name Date lu -— <br />CE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />APPLICANT MUST PERFORM ALL WZPE <br />JOAQUIN COUNTY, ENVIRONMENTAMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 't CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK RMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'$ COMPENSATION LAWS ONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br />THAT IN THE PERFORMANCE OF THH THIS PERMIT IB ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' <br />L'oZZ016• <br />I <br />A i-�e <br />Applicant's Title Pato <br />BILLING INFORMATION: <br />Indicate the responslbl 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 A & S Engineering_ _ „ _„, TITLE Agent for Tesoro PHONE i 661-25 9300 <br />ADDRESS 28405 Sand Qj0yQ0 Ewd,-Qanyon Country, CA 91367 <br />SIGNATURE_ DATEE__ <br />EH230038 (revised 07-17-2014) <br />2 <br />Received Time Apr, 13, 2017 2:30PM Flo, 1250 <br />