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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dulcinea Webb916-373-1166 <br /> C Facility Name Fast Lane Lathrop Phone# 707-326-0369 <br /> L <br /> Address 116 E. Roth Road <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Christina Gill Phone# 707-326-0369 <br /> C Contractor Name Walton Engineering, Inc. Phone# 916-372-1888 <br /> 0 <br /> NContractor Address P.O. Box 1025 NCA 617238 Class HAZ A, B <br /> T <br /> R Insurer State Fund Work Comp# BB1093003 <br /> A <br /> T ICC Technician's Name Gerardo Guzman Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> 87 sump 20 K Gasoline 87 <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Aproved Approved with conditions ElDisapproved <br /> L (SelXlachmentlNith Conditions) <br /> A <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 /> JOAQUIN 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 CALIFORNI " <br /> Applicant's Sign re TiteC O �� Date <br /> BILLING IN ORMATION: <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 <br /> ed <br /> EH230038(revis0/09) <br /> 1 <br />