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SAN JOA U1 <br />--COUNTY <br />Environmental Health Department <br />MAY 2 3 2023 <br />FN\/IRONMEN IAL t -IE ,I Il <br />APPLICATION FOR UNDERGROUND STORAGE TANK PERMIT/SERVICI_'- <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM <br />I, <br />APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />jKTANK <br />RETROFIT ❑ PIPING REPAIR/RETROFIT <br />❑ <br />UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />C <br />Facility Name CHEVRON #94275 <br />Environmental Health Department <br />MAY 2 3 2023 <br />FN\/IRONMEN IAL t -IE ,I Il <br />APPLICATION FOR UNDERGROUND STORAGE TANK PERMIT/SERVICI_'- <br />RETROFIT OR PIPING REPAIR PERMIT <br />F <br />THIS PERMIT EXPIRES 180 DAYS FROM <br />THE <br />APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />jKTANK <br />RETROFIT ❑ PIPING REPAIR/RETROFIT <br />❑ <br />UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # DYLAN SMITH 916-730-7906 <br />C <br />Facility Name CHEVRON #94275 <br />Phone #760-707-3396 <br />1 <br />Address2905 WEST BENJAMIN HOLT DR, STOCKTON, CA. 95207 <br />L <br />T <br />Cross Street PLYMOUTH RD <br />Y <br />Owner/Operator CHEVRON PRODUCTS COMPANY <br />Phone #760-707-3396 <br />C <br />Contractor NameWAYNE PERRY INC <br />Phone #916-646-9680 <br />0 <br />N <br />Contractor Address 30 MAIN AVE SUITE #5 SACRAMENTO <br />CA Lic# 300345 Class A(C21/C10) B(C61040) <br />T <br />HAZ/C <br />A <br />Insurer EVEREST NATIONAL INS. CO. <br />Work Comp#CA 10003737221 <br />T <br />ICC Technician's Name BRANDON SMITH <br />Expiration Date 1/4/2024 <br />R <br />ICC Installer's NameBRANDON SMITH <br />Expiration Date 1/4/2024 <br />Tank system work area <br />Tank Size <br />Chemicals <br />Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />REGULAR UNLEADED TANK <br />303000 <br />87 GASOLINE <br />T <br />A <br />N <br />K <br />SPLIT TANK <br />20,000 <br />14,000 PREMIUM 91 GASOLINE/ 6,000 DIESEL <br />P <br />❑ Approved * Approved with conditions <br />❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name��, Date <br />APPLICANT <br />MUST PERFORM ALL 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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />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 />D �mz PERMIT TECH <br />5/8/2023 <br />Applicant's <br />Signature Title <br />Date <br />IJ <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br />acknowledge this responsibility for the billing by signature and date below. <br />NAME DYLAN SMITH TITLE PERMIT TECH PHONE <br />ADDREss 30 MAIN AVE SUITE #5, SACRAMENTO, CA. 95838 <br />SIGNATU <br />s <br />916-730-7906 <br />5/8/2023 <br />