Laserfiche WebLink
DEC 11 2015 <br /> ENVIRONMENTAL HEALTH DEPARTNS ` IRONMENTAL <br /> {.: r1�pA DTA ACA IT <br /> SAN ,iOAQUIN COUNTY r=:91 T4 <br /> 600 East Main §treet, 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 I BO DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT 10 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT Ej COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Mark Shaw <br /> A Facility Name Phone# <br /> C Y Shell Terminal 916-503-2538 <br /> IAddress <br /> L 3515 Navy Dr.,Stockton CA 95203 <br /> TCross Street <br /> Y Owner/Operator Ron Bronson Phone# 714-755-7257 <br /> G Contractor Name Able Maintenance Phone# 707-545-5522 <br /> 0 <br /> T Contractor Address 3224 Regional PkWy Santa Rosa,Ca.95403 CA Lie# 312844 ClassB,A,C61/D40d <br /> R Insurer <br /> A State Compensation Insurance Fund Work Comp# 9073219-15 <br /> T ICC Technician's Name M 0 K� -fA'-e-?� Expiratlon Date 7—L7-/7 <br /> q ICC Installer's Name ,pt t k 1-N 6-TO Expiration Date I—23 -/ <br /> Tank system work areaP01140 UDC Date UST <br /> li.e.87 plping..', tlelePtoq 102,eN.I Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P Ej Approvedpproved With conditions El Disapproved <br /> e� c <br /> L (S entWithConditions) <br /> A /-x <br /> N Plan Reviewers Name Date /-x�AP//✓5 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN,JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES SAND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 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 WORKERS 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 /> Appllcanra SgnawreG Tm§ Compliance Manager ped 12/7/2015 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff timeexpended 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 /> NAMEMark Shaw TITLE Compliance Manager PHONE# (916)503-2536 <br /> I <br /> ADDRESS 2519 Evergreen Ave W.Sacramento,Ca.95691 <br /> SIGNATURE <br /> DATE 12/7/2015 <br /> EH230038(revised 02/20/09) <br /> 1 <br />