Laserfiche WebLink
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 ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT 9 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> APhone# 209 465-8979 <br /> C Facility Name US Gasoline <br /> L <br /> Address 749 E Charter Way Stockton 95206 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# 209 465-8979 <br /> o Contractor Name APEC Phone# (209) 943-3000 <br /> NContractor Address PO Box 55105-Stockton, CA 95205 CA Lic# 341375 Class q B/C-10 <br /> T <br /> A Insurer State Fund Work Comp# 238-0005332 <br /> T ICC Technician's Name Gavin R Williams (801628$ ) Expiration Date 816112 <br /> RICC Installer's Name NIA Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stared Currently Date UST <br /> (i.e.67 piping sump,91 leak detector,UPC 1,12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P [ Approved _ Approved with conditions Disapproved <br /> L (S e Attachment With Conditions) <br /> A r/ <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY, ENVIRONMENTAL 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 /> Applicant's Signature i `""' <br /> ,{sem Title Authorized Agent Da1e 11/14110 <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, tate party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME APEC TITLE Contractor PHONE# (209) 943-3000 <br /> ADDRESS PO Box 55105Stockton, CA 95205 <br /> SIGNATURE <br /> C°—'r ' //� DATE 11/14/10 <br /> EH230038(revised 02/20109) <br /> 1 <br />