Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTII1RECEIVEL <br />SAN JOAQUIN COUNTY OCT 13 2015 <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL. <br />HFAITN MIDAIDTAMNIT <br />APPLICATION FOR UNDERGROUND STORAGE TANK 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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Liddy McKenzie (925.551.7555) <br />A <br />C <br />Facility NameCHEVRON SS#201383 <br />Phone# 925.842-1000 <br />I <br />L <br />Address 1960 W. 11 TH STREET, TRACY, CA <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator CHEVRON PRODUCTS COMPANY <br />Phone# <br />C <br />0 <br />Contractor NameGettler-Ryan Inc <br />Phone # (925) 551-7555 <br />T <br />Contractor Address 6805 SIERRA CT, SUITE G, DUBLIN, CA94568 <br />CA Lic # 220793 CIaSSA, B,C1 0,C57,C-61040,HAZ,HIC <br />A <br />Insurer State Compensation Ins Fund <br />Work comp # 9051229-3 <br />T <br />ICC Technician's Name BRIAN GANN <br />Expiration Date <br />R <br />ICC Installer's Name MIKE O'SULLIVAN <br />Expiration Date <br />Tank system work area <br />87 91 leak detector, UDC 1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. piping sump, etc.) <br />SUPREME UNLEADED <br />12,000 <br />GASOLINE <br />T <br />N <br />DIESEL <br />12,000 <br />DIESEL <br />K <br />REGULAR UNLEADED <br />12,000 <br />GASOLINE <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 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 <br />TO 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 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." 7 <br />f�� �--�— <br />Applicant's Signature Title AGENT FOR OWNER 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 for the billing by signature and date below. <br />NAMIE Liddy McKenzie TITLE Project Manaqer PHONE #925.551.7555 <br />ADDREss6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br />SIGNATURE J DATE l'�S <br />EH230038 (revised 02/20/0 <br />1 <br />