Laserfiche WebLink
0 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> TE <br /> SAN JOAQUIN COUNTY R CO'Aq ) <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 JAN 17 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TAI'91VIRONMENT.AL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT D F P A Pi TMENIF <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#MERLIN BOWEN 925.551.7555 <br /> A Facility Name CHEVRON SS#208117 Phone#209.830.0370 <br /> 1 Address 755 SOUTH TRACY BLVD <br /> L <br /> T Cross Street WEST SCHULTE ROAD <br /> Y Owner/OperatorCHEVRON PRODUCTS COMPANY Phone#925.842-1000 <br /> Contractor Name Gettler Ryan Inc. Phone#925.551.7555 <br /> O <br /> N Contractor Address 6805 Sierra Court, Suite G, SUITE G CA Lic _ T p j Class/¢ Cbl <br /> T <br /> A Insurer State Compensation Ins Fund Work Comp#9051229-3 <br /> T <br /> T ICC Technician's Name BRIAN GANN Expiration Date <br /> R ICC Installer's Name MIKE O'SULLIVAN Expiration Date <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 SUPREME UNLEADED 20,000 GASOLINE <br /> A REGULAR UNLEADED 15,000 GASOLINE <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> LAttachment With Conditions) <br /> A <br /> N 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: "1 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 PERFORMAN OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant'sSignature Title Date <br /> FOR OWNER 1/12/2018 <br /> 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 /> NAME Liddy McKenzie TITLE Project Manager PHONE#925.551.7555 <br /> ADDRES56805 RRA CT, SUITE G, DUBLIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(rev ed 07-17-2014) <br /> 2 <br />