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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 10 PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT [3 COLD START/EVR UPGRADE <br /> A F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> C Facility Name Chevron Phone# 209-477-4294 <br /> IAddress <br /> L 6633 Pacific Ave,Stockton CA 95207 <br /> I Cross Street <br /> Y Owner/Operator Chevron Phone# <br /> 209-477-4294 <br /> oContractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 ClaSSB C61/D40 HAZ <br /> AInsurer ICW Group Work Com # <br /> C <br /> P WPL502130700 <br /> T ICC Technician's Name Justin Graves Expiration Date 2/28/2014 <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currents Date LIST <br /> (Ee.87 piping sump,91 leak detWor,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approvedpproved with conditions <br /> 0 Disapproved <br /> A e Attachment With Conditions) <br /> N <br /> Plan Reviewers Nam f DatLI-41 <br /> , <br /> APPLICANT MUST PERFORM At�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: '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 WORKERS 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.` <br /> Applicants Signature L Compliance Officer Data 11/26/2012 <br /> BILLING INFORMATION: <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 /> SIGNATURE U ` 1 DATE 11/26/2012 <br /> EH230038(revised 02/20/09) <br /> 1 <br />