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SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, Califomia 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 10 PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br />c <br />Facility Name Valero #3641 Phone # 209477-3111 <br />I <br />L <br />Address 1210 E Hammer Lane, Stockton CA 95210 <br />TCrass <br />Street <br />Y <br />Owner/Operator Valero Energy Corp. <br />Phone # 209477-3111 <br />C <br />0 <br />Contractor Name Able Maintenance, Inc. <br />Phone # 7Q7_545-5522 <br />T <br />Contractor Address 3224 Regional Parkway, Santa Rosa 95403 <br />CA Lic# 312844 Class B A C10 HAZ <br />R A <br />Insurer Insurance Company of the West Work Comp # WPL500060303 <br />T <br />ICC Technician's Name Expiration Date <br />oICC <br />R <br />Installer's Name Kelly Burnin ham Expiration Date 12/17/2012 <br />Tank system work area Tank Size Chemicals Stored Curren/ Date UST <br />Ii.e. 87 piping sump, 91 1ek detector, UDC U2, eft.) Currently <br />Installed <br />T <br />A <br />N <br />K <br />v, <br />P <br />® Approved Approved with conditions Disapproved <br />.1 (See Attachment With Conditions) <br />A <br />N <br />_- <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL VyOfK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMEW AL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKERS COMPENSATION LAWS OF CALIFORNIA.` CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 <br />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.' ff <br />Applicartrssig".. dto4` �'' � }-i't��L-`Lt�. i Compliance Officer 6/25/2012 <br />Dao® <br />v tevrvrRmNt 116JIV: <br />Indicate the responsible 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 Marty Weithman TITLE Compliance Officer PHONE# (408) 213-6038 <br />ADDRESS 680 Quinn Ave. San Jose, 95112 <br />no <br />EH230038 (revised 02/24/09) <br />F� <br />6/2512012 <br />