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RECEIVED <br />AfOR 13 2017 <br />ENVIRONMENTALHEALTHE <br />iT/SERVIENTAL HEALTH <br />E <br />SAN JOAQUIN COUNTY <br />RECEIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 488-3420 Fax: (209) 468.3433 OCT 18 2016 <br />APPLICATION FOR UNDERGROUND STORAGE TINK V IRONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT IV <br />THIS PERMIT EXPIRES 180 DAYS FROM TME APPROVAL UATE. INDICATE PERMIT TYPE BELOW: DEPARTMEIV 1��g- <br />LJ(TANK RETROFIT ❑ PIPING REPAIRIRETROFIT n UOC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # A & S EngkwwN Ahmad Ghaderl 1661.250.9300 <br />C <br />Facility Narne —T—Phone# <br />661-250-9300 <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 Ro6ning & Marketing Complan LLC <br />Phone # 210-628-8224 <br />G <br />0 <br />Contractor Name Fuel Pros Inc, <br />Phone # 909-614-1379 <br />N <br />Contractor Address 14774 Central Ave, Chino, CA 91710 <br />CA Lie# 269364 Class A, C36, B <br />A <br />Insurer Midwest Employers Casualty Company <br />Work Comp # BNUVVC0133329 <br />T <br />ICC Technician's Name Raul Vas uez <br />Expiration Date 12/9/2017 <br />R <br />ICC Installer's Name Raul Vasquez <br />Expiration Date 3/10/2018 <br />Tank ayetem work area Tank Size <br />U M1119 GUM% el Ifflk ftseW, Loc 112, 61G.) <br />Chemicals Stored Currently Date UST <br />installed <br />T <br />Existing to Remain <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />? <br />Plan Reviewers Name ' Date <br />NCE IMTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />APPLICANT MUST PERFORM ALL WZWHIIS <br />JOAQUIN COUNTY, EWRONMENTTMENT. OMER OR uCENSEo AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />HE PERFORMANCE OF THE WORKPERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCHA MANNER AS TO BECOME SUBJECT TO <br />KEW$ COMPENSATION LAWSCONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br />THAT IN THE PERFORMANCE OF TCH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />L® t d I (j. <br />A Ilcanl's Signature Tide Date t.2 <br />BILLING INFORMATION: <br />Indicate the responsibl 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 Englrleerirl TITL Agent for Tesoro PHONE # 861-250-9300 <br />ADDREss 28405 Sansi,Q��ggd, Ganyon Country, CA 91357 <br />SIGNATURE,„___, DATE <br />EH230038 (revised 07-17-2014) <br />Received Time Apr. 13. 2017 2:30PM No. 1250 <br />