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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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT D PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT [I COLD START/EVR UPGRADE <br /> FEPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> c Facility Name Chevron Phone# 209-836-3181 <br /> 1Address <br /> L 1960 W 11 th St,Tracy CA 95376 <br /> 1 Cross Street <br /> T Corral Hallow <br /> Y Owner/Operator Chevron USA Phone# 925-842-9002 <br /> C Contractor Name y Phone# <br /> D Service Station Systems, Inc. 408-213-6038 <br /> N Contractor Address <br /> 7 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> A Insurer ICW Work Comp# WPL502130701 <br /> T ICC Technician's Name Randy Wilkerson Expiration Date 5/2/2015 <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> i i.e.87 piping awnp,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved RApproved with conditions In Disapproved <br /> L <br /> A (see Attachment With Conditions) <br /> N Pian Reviewers Name / <br /> Date ( a%14��� <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 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 /> AppecenraSignature Ppb ty-i L t 1 k,Lie Compliance OfficerDei 11/25/2013 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff lime 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 Marty Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave.San Jose,95112 <br /> SIGNATURE wi DATE 11/25/2013 <br /> EH230038(revised 02!20/09) <br /> 1 <br />