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ENVIRONMENTAL HEALTH DEPARTMENT, <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,Caffornia 95202 <br /> Telephone: (209)468-3420 Fax:(209)4603433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES IN DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ® TANK RETROFIT ® PIPING REPAIRIRETROFIT ® UDC'REPAI ETROFIT Q COLL)START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Chevron Phone# 209.477-4294 <br /> IAddress <br /> L 6633 Pacific Avenue,Stockton CA 95207 <br /> I Cross Stmt <br /> T Ben'amin Holt <br /> Y Owner/Operator Chevron USA <br /> Phone# 253-896-8700 <br /> o Contractor Name Service Station Systems, Ina Phone# 408-213-6038 <br /> Y Contractor Address 680 Quinn Avenue �CA Lia# 485184 <br /> R Classg C61/D40 HAZ <br /> Insurer <br /> A Cypress Insurance Company Work Comp# 3310020636091 <br /> T ICC Technician's Name Matt Estabrook Expiration Date 5/28/2011 <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current Date UST <br /> (i.e.87 Oft SWW,91 k de ,UDC 1rz,etc.) � In Date <br /> lledT <br /> A <br /> N <br /> K <br /> P ®Approved JM Approved with conditions Disapproved <br /> L 9 (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name r Date I? / O <br /> APPLICANT MUST PERFORM ALL W KIN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURECERTIFIES THE FOLLOWING: `I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK:FOR WHICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO13ECOME 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.` <br /> ApplkanreS L` ` Compliance Officer Date 2/17/2010 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment cov a per tante. 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 bailing 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 � -e DATE 2/17/2010 <br /> EH23DO38(revised 02/20/09) <br /> 1 <br />