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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />39() 1868 E. Hazelton Ave., Stockton, California 95205 HL'UtIVO, <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 JUL 3 <br />2 9 20115 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAI, <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT gKPIPING REPAIRIRETROFIT 0 UDC REPAIR[RETROFIT 0 COLD STARTIEVR UPGRADE <br />F EPA Site # Project Contact & Telephone # <br />C <br />A Phone# loncix -Q':)1;-A565 <br />Facility Name Sinclair <br />Address 1001 E. Yosemite.. <br />L <br />I Cross Street <br />T Owner/Operator Monterey Fuel hone # <br />Contractor Name. KaiSer C Phone# <br />o <br />Contractor Address P0 Box 1,058, Linden -CA -952-36 CA Lic # 8595 Class A <br />T <br />R comp # 1839765-14 <br />A Insurer State Fund <br />Cpiration Date 04/14/2017 <br />T ICC Technician's Name G[eg Kaiser... <br />0piration Date <br />ICC Installer's Name 5252318Ex <br />. Date UST <br />Tank system work area Tank Size Chgiilicals Stored Currently Installed <br />0.e. 87 piping swop, 91 leak deledor, UDC 1/2, <br />T <br />A <br />N <br />K <br />P❑ Approved Approved with conditions D Disapproved <br />L (S Attachment With Conditions) <br />A <br />N Plan Reviewers Name \j I..,\) IQ V4 Date <br />j?'-- <br />,LICANT MUST PERFORM ALL WORK IN ACCORDANIC TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />I T OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />WIN COUNTY, ENVIRONMENTAL HEALTH DEPART ENT. <br />THIS <br />L NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />0 <br />'PERFORMANCE OF THE WORK FOR WHICH THIS ERMITIS ISSUED, I SHALL ING SIGNATURE CERTIFIES THE FOLLOWING: q CERTIFY <br />�RKEFVS COMPENSATION LAWS OF CALIFORN CONTRACTOR'S HIRING OR SUBCONTRACT <br />kT IN THE PERFORMANCE OF THE RK /FORICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br />CALIFORNIA" <br />Title <br />BILLING INFORMATION: <br />Indicate the responsible party be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />- a pa 0 than the <br />must acknowledge this <br />the party designated bel is different than the permit applicant, e.g. property owner, the party <br />0 t a _ below. <br />.1 'a <br />responsibW ity for the llin y gnature and date <br />P <br />NAMETITL HONE <br />EH230038'(f)dvfsed 10MO/12) <br />9 <br />