Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY 0 <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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dulc inea Webb 916-3 73-116 6 <br /> C Facility Name Fast Lane Lathrop Phone# 707-326-0369 <br /> I <br /> L Address 116 E. Roth Road <br /> TCross Street <br /> Y Owner/Operator Christina Gill Phone# 707-326-0369 <br /> c Contractor Name Walton Engineering, Inc . Phone# 916-372-1888 <br /> N Contractor Address P.O. Box 1025 CALic# 617238 Class HAZ A, B <br /> T <br /> A Insurer State Fund Work Comp# BB1093003 <br /> T ICC Technician's Name Gerardo Guzman Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.97 piping sump,91 leak detaotor,UDC 1/2,etc.) Installed <br /> T 91 STP sump 12 K Gasoline 91 <br /> A <br /> N <br /> K <br /> P ❑ Appr ved Approved with conditions Disapproved <br /> L See ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date ( D <br /> APPLICANT 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 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 CALIFORNI 0 <br /> Applicant's Title Co \�°V"_ <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 Dulcinea Webb TITLE Compliance ManagerPHONE# 916-373-1166 <br /> ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE DATE ` 1Ir,` _I(7 <br /> EH230038(revised 02120/09) <br /> 1 <br />