COMPLIANCE INFO_2001-2009 - Laserfiche WebLink

Home Browse Search

19255517888 Main Fax GETTLER RYAN INC 10:09:37 a.m. 12-06-2006 5/10 to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3" 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 RFPAIR/RETROFIT +----`-------------------------------------------------------------------------------------------------- EPA SITE # ; PROJECT CONTACT 6 TELEPHONE # Liddy McKenzie 925 F FACILITY NAME Olympian "Flyers": PHONE # 925 551-7555 A____________________________________________________________________________________________ +____---_--_ C ADDRESS 483 Moffat Blvd ' I +__________________-------------------------------------- L _ ____________________ _______- L CROSS STREET I--------------------------------------------------------- T OWNER/OPERATOR Y -------------------------------------------------------- C CONTRACTOR NAME Gettler Ryan InC. 0 ----------------------- - N 1 CONTRACTOR ADDRESS 6747 Sierra Court, Suite J T+-------------------------------------------------------- R INSURER State Fund A________________________________________ _--_____- 1 C ; OTHER INFORMATION T+--------------`----------------------------------- O ;_____________________________ TANK ID I$ TANK SIZE PHONE # $51-7555 -------------------------+----- PHONE # 925 551-7555 -------------------------- - --- ----------------- Dublin ; CA LIC # ; CLASS a,b,c-10,haz,c57,c61,d40 --------------------- ---------------------------- WORK. COMP .# 428-2004 ___________________________+__.--_-_________________-_-_---__________� __________________________♦_________-__---_-_____-_-_______-_---_- PHONE # 925 551-7555 -------_._`-----------------+---------------- PHONE # -___ _______________________----__-_-_______ CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED 39- T 39- A 9-A 39- N 1 39- K 39- 39- 39- .......... LAPPROVEDpSs. APPROVED WITH CONDITIONS) DISAPPROVED A ATTACHMENT WITH CONDITIONS) _ p N PLAN REVIEWERS NAME ® DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OP 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 C TFORNTA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE O E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.% APPLICANT'S SIGNATURE:-- Permit Expeditor +-------------------- --------------- ----- ----- — -- -------------------------+ 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 Liddy McKenzie Address Dublin 94566 Phone # 925 551-7555 Signature EH230038 (revised 1/31/02)