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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT PE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT OLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Bill Schwartz - 925-426-6626 <br />A <br />C <br />Facility Name Site 300 <br />Phone # 925-423-7173 <br />� <br />Address Corral Hollow Road, Tracy, CA 95376 <br />TCross <br />Street <br />Y <br />Owner/Operator Lawrence Livermore National Laboroatory <br />Phone # 925-423-7173 <br />c <br />O <br />Contractor Name Central Petroleum Maintenance <br />Phone # 925-462-4060 <br />T <br />Contractor Address 176 Wyoming Street, Pleasanton, CA 945667 <br />CA Lic # 491948 Class C61 /D40 <br />A <br />Insurer Mid Century Insurance <br />Work Comp # B19536158 <br />T <br />ICC Technician's Name Gregg Geltz <br />Expiration Date <br />o <br />R <br />ICC Installer's Name 5250561 -UT <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <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 />Plan Reviewers Name Date as-- 'a �( <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." � /f <br />Applicant's Signature ti'i!y'� Title C U Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME Kathleen Henshaw TITLE CFO PHONE # 925-462-4060 <br />ADDRESS 176 Wyoming Street, Pleasanton, CA 94566 <br />SIGNATU <br />EH230038 (revised 07/22/10) <br />2 <br />TE 05/18/11 <br />