COMPLIANCE INFO_2004 - 2007 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.3RD FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: /TANK RETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------- ----------------------------------------- ------------------------------------------ ----------+ EPA SITE # ; PROJECT CONTACT & TELEPHONE # Scott Polston 925 551-7555 --------------------------------- # - -- --- PHONE F ; FACILITY NAME Arco Service Station#06080 925 551-7555 IA +------------------------------------------------------------------------------------------- --------------------------- C I ADDRESS 85 East Louise Avenue i ' --- --- --------- -------------- ----------------' L ; CROSS STREET South Haden Road ' I +------------------ --- --- --------------------- T 1 OWNER/OPERATOR PHONE # Y ; Sarpa's Ampm MInI-Market (209)9113-9140 , '---+-------------------------------------------- -- --------------------+- C ; CONTRACTOR NAME Gettler Ryan Inc. ; PHONE #925 551.7555 ' 0 +------------------ ------------------------------------- N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin ; CA LIC # 220793 I CLASS a,b,c-10,haz,c57,c61,d40 ' T +-------------------- --- - ------------ ------ ----------------- -- R INSURER State Fund ; WORK.. OMP.# 428-2004 A '------------------------------------------------------------------------------------+------------------------ ----! C ; OTHER INFORMATION ------------------ ---------------I T +------------------- ; PHONE # 925 551-7555 ' O , PHONE # ---------------------------------------------------------------------------------------------- � TANK ID # 111111'1 , TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39- 39- 39- P 9-39- 39-P L ; APPROVED ' APPROVED WITH CONDITIONS) DISAPPROVED A WA ATTACHMENT WITH CONDITIONS) N ; PLAN REVIEWERS NAME �1♦. WA _____ DATE +---illllllll1. . . . llllliiilllllllllllllllll APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S RING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE P O CE OF THE W FOR ��CTHIS IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL RNI Permit Expeditor A!lLICANT'S SIGNATURE: TITLE DATE +------------------------------------------------------------------------------- ----------------------+ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. 6747 Sierra Court,Suite J Name SCOtt POIStO lin sassy Phone # 925 551-7555 r Signatur EH230038 (revised 1/31/02)