Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPA UNJEIVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 2 5 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ENVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEPARTMENT <br /> 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 9XUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Jesse (209) 957-5398 <br /> A <br /> C Facility Name SHELL Angles Petroleum Phone# (209) 957-5398 <br /> 1 Address <br /> L 7700 Moreland Court, Stockton, CA 95212 <br /> 1 Cross Street Hammer Lane <br /> T <br /> Y Owner/Operator Mr. Angle Phone# (510) 552-4822 <br /> oContractor Name Kaiser Commercial Petroleum Phone# (209) 887-2639 <br /> N Contractor Address PO Box 1058, Linden, Ca 95236 CA Lic# 859535 Class A <br /> T <br /> A Insurer Brown & Brown Ins Svc of CA, PO Box 200, Stockton Work Comp# 1839765-17 <br /> C ICC Technician's Name g <br /> T Greg Kaiser ICC#5252318 Expiration Date 10-13-19 <br /> R ICC Installer's Name Greg Kaiser ICC#5252318 Expiration Date 04-11-19 <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 UDC 5&6 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> Lee Attac ment With Conditions) <br /> A J <br /> N Plan Reviewers Name�f 1 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: "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 PERFORMA CE 9F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." I, <br /> Applicant's Signature ' Tile Authorized Contractor Date 10/23/2017 <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 Mr. Angle TITLE Owner PHONE# (510) 5524822 <br /> ADDRESS 7700 Moreland urtStock A 95212 <br /> SIGNATURE DATE 10/23/17 <br /> EH230038(revised 10/30/12) 1/ <br /> 2 <br />