Laserfiche WebLink
ENVIRONMENTAL HEALTFi DEPARTM <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Clifornia 95205 <br />Telephone: (209) 468-3420 Fax: r209) 468-3433 <br />APPLICATION FOR UNDERGROUNO STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />C�ivtr <br />MAR 0 9 2015 <br />ENVIRONMENT _, <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br />r. -'TANK RETROFIT a PIPING REPAIRIRETROFIT G UDC REPAIR/ ETROFIT C COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & TeIE phone # <br />� <br />Facility Name Village West Marina <br />1Phone # A011 % j�"—�� <br />� <br />Address 6649 Embarcadero Drive Stockton CA 9 <br />219 <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # <br />o <br />Contractor Name Kaiser Commercial Petroleum <br />Phone # <br />N <br />T <br />Contractor Address PO Box 1058, Linden, CA 95236 <br />A Lic # 859535 Class A <br />A <br />Insurer State Fund <br />Work Comp # <br />T <br />ICC Technician's Name Greg Kaiser, 5252318 <br />Expiration Date 9-15-2015 <br />R <br />ICC Installer's Name Greq Kaiser, 5252318 <br />Expiration Date 4-22-2015 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />U.e 87 piping sump 91 iesk detedor UDC 112 etc <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with con tions Disapproved <br />L <br />(See Attachment With Conc itions) <br />A <br />N <br />�7 <br />Plan Reviewers Name f <br />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 IGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY NY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTR <br />CTING SIGNATURE CERTIFIES THE FOLLOWING' "I CERTIFY <br />THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMP <br />OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA " Z7 <br />/ <br />L <br />Applicant's Signature !/ 'N iiii .tet Title <br />GW Date 3 17— 1 1 r <br />BILLING INFORMATI <br />Indicate the responsible party to be billed for additional EHD staff time exper <br />the party designated below is different than the permit applicant, e.g. p <br />responsibility for the billing by signature and date below. <br />NAME \1,k\i; Qj� 11AC,,lr'At., TITLE J�'� <br />EH230038 (revised 10/30/12) <br />2 <br />beyond permit payment coverage per tank. if <br />rty owner, the party must acknowledge this <br />PHONE #CZ� `5 I <br />2I `i <br />TE�II L I t - <br />