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ENVIRONMENTAL <br /> SAN JOAQUIN <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 ® PIPING REPAIRIRETROFIT ® UDC REPAIR/RETROFIT ® COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> D Facility Name Chevron USA Phone# <br /> I 209-477-4294 <br /> L Address 6633 Pacific Ave Stockton CA 95207 <br /> TGross Street <br /> Y Owner/Operator Chevron USA Phone# <br /> 209-477-4294 <br /> C Contractor Name Service Station Systems, Inc. Phone# <br /> o Y 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lic# 485184 Glassg C61/D40 HAZ <br /> R Insurer <br /> A Cypress Insurance Company Work GomR# 3310020636091 <br /> T ICC Technician's Name Bryan Lundien Expiration Date 10/23/2011 <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currents Date UST <br /> (i&87 piping sump,91 Ink detector,UDC V2,etc.) Y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approved Approved With conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name I <br /> Date <br /> APPLICANT MUST PERFORM ALL W IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENT 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." <br /> ApplicanrsSi9neture V Compliance Officer Data 1/19/2011 <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 DATE 1/19/2011 <br /> EH230038(revised 02!20/09) <br /> 1 <br />