COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT r THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS- INDICATE PERMIT TYPE BELOW: X TANK REPAIR/RETROFIT `TANK LINING PIPING REPAIR BILLING INFORMATION: 55- 560 Indicate the responsible party to be bitted for additional PHS -END 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 bitting by signature and date betow. Name Robert H. Lee & Assoc., Inc. ... Attn: Sharvn Mitchell Mailing Address 1137 North McDowell Blvd., Petaluma, California 94954 EPA SITE B CAL000029680 PROJECT CONTACT $ TELEPHONE ffSharyn Mitchell/Craig Schafer (707) 7 F A FACILITY NAME LINCOLN VILLAGE WEST CHEVRON J. PHONE 4209) 478-5555 �- C 1 ADDRESS 2905 WEST BENJAMIN HOLT DRIVE, STOCKTON, CALIFORNIA 95207 -- L CROSS STREET PLYMOUTH ROAD T OWNER/OPERATOR PHONE 0 Y CHEVRON PRODUCTS, INC. (510) 842-9500 C' D CONTRACTOR NAME To be determined. PHONE 0 N CONTRACTOR ADDRESS CA LIC 4 CLASS T - -- R INSURER WORK.COMP.# A C OTHER INFORMATION 0 PHONE iJ R -- - •- IIiIIIIIIIIIIIIIfIfill iIIIIIII PHONE # TANK to 0 TANK S12E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 1 12.000 szallon plus unleaded 1989 T 39 -gal on su reme unleaded-- A 39- . QOO " 1 on unleade N K 39- 4 39- 9 12,000 gallon _ unleaded 1Q.000 gallon, _, methanol 199-1 39- 9 -39- 39- I P L APPROVED APPROVED WITH CONDITION(S) � DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE nlnlllll��►I�nlrl t , , �� I , IIllfill [III III if I III 111111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 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'$ HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE I INXC o Robert H. Lee & Assoc. TITLE• Job Captain DATE �9 gent for Owner BILLING INFORMATION: 55- 560 Indicate the responsible party to be bitted for additional PHS -END 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 bitting by signature and date betow. Name Robert H. Lee & Assoc., Inc. ... Attn: Sharvn Mitchell Mailing Address 1137 North McDowell Blvd., Petaluma, California 94954