Laserfiche WebLink
i � � <br /> ENVIRONMENTAL HEALTH D :EPARTM NOT 2019 <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton , California 95202 EINVi H, 01VWiENIT AL <br /> Telephone : (209) 468-3420 Fax : (209) 468-3433 HEA13H r) FPARTM `vN <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 /> 8 TANK RETROFIT PIPING REPAIR/RETROFIT B UDC REPAIR/ RETROFIT B COLD START/EVR UPGRADE <br /> FA F EPA Site # Project Contact & Telephone # Marty Weithman 408-213-6038 <br /> Facility Name Unocal 76 #255886 Phone # <br /> 209-473-7337 <br /> L Address 2701 W March Lane , Stockton CA 95219 <br /> T <br /> Cross Street 1 -5 <br /> Y Owner/Operator Darren Eppler Phone # 209473-7337 <br /> C Contractor Name Able Maintenance Phone # <br /> 0 408-213-6038 <br /> N Contractor Address <br /> T 3224 Regional Pkwy , Santa Rose CA 95403 CA Lic # 312844 C18ssg .A , C10 <br /> AInsurer State Comp Ins Fund Work Comp # 9073129 <br /> C ICC Technician's Name <br /> T Expiration Date <br /> QICC Installer's Name <br /> R Kelly Burningham Expiration Date 1 /20/2019 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le 87 piping sump, 91 leak detector, UDC V/2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions [2 Disapproved <br /> L (SeAA achment With Conditions ) <br /> A 2 <br /> N Plan Reviewers Name_ 1E , Mouli 2 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 AGENT'S 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 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 /> Applicenrs Signature G t `tom ejLC L Tj00 Compliance Officer Date 12/28/2018 <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 Marty Weithman TITLE Compliance Officer PHONE # 408-213-6038 <br /> ADDRESS 680 Quinn Ave . San Jose , 95112 <br /> ll nn ' I <br /> SIGNATUREftczt.f�v ,' � v �-ctt�L4 DATE ' ' It 4 am Nay <br /> EH230038 (revised 02/10/09) <br /> 1 <br />