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SAN JOAQUIN COUNTY ENVOONMENTAL HEALTH DEFWTMENT 304 E WEBER AVE, 3M FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: . WY �TANK'RETROFIT PIPING REPAIR/RETROFIT ,UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT I+---i-----------------------------------------------------------------------------------------------------------------------------+ EPA SITE # I PROJECT CONTACT & TELEPHONE# �'d(O,7 C!I'�At110 (RN4.� us 31s-°1700 --------------------•--------------� F I FACILITY NAME :W 9 - 1640 Ghevran i'rG&Cts Co. 1 PHONE # I IA +----------- -------------------------------------------------------------------------------------------------------------i I c I ADDRESS -+344 kl2ter'it>o Ro2A . 5i-oc.kfion , 615215 I------ ----------------------------------I L I CROSS STREET -- 1 II+-----------------------------------------------------------------------------------------------------------------------------i Y i O /� Gheavron froduots Co. (Attn: David Lyons i PHONE # (g25�842-4387 I C I CONTRACTOR NAME SavidGjG Construetldrl 1r, r- I PHONE # (53o) 0022- 1982 Io +----------------------------------------------- ------------------------------------------------------------------------I N I CONTRACTOR ADDRESS C .e 401 z>n�2 &UYIy,, r�=r t'tei CA LIC # 755848 1 CLASS A , HAR. I T+---------------�--�-}-------------------------------------------------------------------------------------------------------I R I INSURER stgte Comf-ens?titin Ir3uranto Fund I womcoMP.# 27S-2003 1 IA 1------------------------------------------------------------------------------------+----------------------------------------I C I OTHER INFORMATION I 1 IT+------------------------------------------------------------------------------------+----------------------------------------I 1 0 1 I PHONE # 1 IR+-------------------------------------------------------------------------------=----+----------------------------------------I I I PHONE # I +---11111111111111111111111111111111----------------------------------------------------------------------------------------------I I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 1 39- 01 I 20,0-00 { req .yr+tG�td I 199 � I T I 39- A 39- I I I I N 139- K 39- 9-K139- I I I I I 39- 39- P 9 -39 -PI 1 I L I _ APPROVED APPRROVED WILT$ CONDITION(S) _ DISAPPROVID A i L:C (�fii`w'— TH CONDITIONS) DATE I N .PLAN REVIEWERS NAME +---IIIIIIIIIIIIIIIIIIIIIIIIIIIIU IIIIIII{III�IIIIIIIIIIIIIIII{IIIIIIIIIIIIIIIIIIIII{111111111111111111111111111111111111111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO COMPENSATION LAWS OF CALIFORNIA." 1 I I APPLICANT'S SIGNATURE: 4 TITLE he—Atfb, Chevron DATE 7/? 1 R 14 if O@319n oW', I rt . I +---------------------------------------------------------------------------------------------------------------------------------+ BILLING INFORMATION: THAT IN.THE Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name RHL j�,j1 n &0uInz-.Address- 1540 Arrlvid Df. Ild Mari'ine� phone # 12-5- *315-1700 - - — - - 84553 exf lob Sig for Chevro-% EH230038 1 (revised 1/31/02)