Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468 - 3420 Fax : (209 ) 468 - 3433 DEC 0 7 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANkNVIRONN ► ENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT ►) EI'/lRTNIENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Angel Rodriguez 916 - 3734165 <br /> A <br /> C Facility Name Tesoro #68222 Phone # <br /> I Address L Add2132 E . Mariposa Road Stockton 95205 <br /> i Cross Street <br /> T <br /> Y Owner/Operator Tesoro Phone # <br /> C Contractor Name Walton Engineering, Inc. <br /> o Phone # 916- 373 - 1165 <br /> N <br /> T Contractor Address P . O . Box 1025 West Sacramento CA 95691 CA Lic # 617238 Class AB HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp # 9113339-2019 <br /> cr ICC Technician 's Name David Delgado - 5246959 Expiration Date <br /> 12-29-2019 <br /> o ICC Installer's Name Expiration Date <br /> R David Delgado - 5246959 p� 9-24-2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N — Replace drop tube . <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A �- f e <br /> N Plan Reviewers Name VM (�� � Date Vfwooe Rig <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 TO <br /> 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 WH H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title 1 " Date <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 it��for the billing by signature and date below. /� <br /> NAME / ' ` t G �, ' �Cn I +_0 TITLE rr`- 5 PHONE # <br /> ADDRESS plot t -�K ICue5f� �f✓C� �j �/-� r�1� 9 <br /> SIGNATURE DATE <br /> EH230038 (revised 7-26-2016) 2 <br />