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• i <br /> 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 /> C� TANK RETROFIT 10 PIPING REPAIRIRETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> D Facility Name Chevron Phone# 209-477-4294 <br /> I Address <br /> L 6633 Pacific Ave,Stockton,CA 95207 <br /> TCross Street <br /> Y Owner/Operator Chevron USA Phone# 925-842-9002 <br /> o Contractor Name Service Station Systems, Inc. Phone# <br /> 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lie# 485184 Class <br /> 13 B C61/D40 HAZ <br /> A Insurer ICW Group Work Comp# WPL502130700 <br /> T ICC Technician's Name Matt Estabrook Expiration Date 5/28/2013 <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currentl Date UST <br /> (Le.67 piping sump,91 leak detector,UDC V2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved (Approved with conditions Disapproved <br /> L <br /> A See Attachment With Conditions) <br /> N Plan Reviewers Name Date / <br /> APPLICANT MUST PERFORM ALL K IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONME AL 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,1 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: '1 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 /> ApplicanrsSignatureb""t, C�.-Eilit ,L �}vk'-C-�' tit (,thee Compliance Officer Dt, 12/27/2012 <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 \ r . DATE 12/27/2012 <br /> EM230038(revised 02/20/09) <br /> 1 <br />