Laserfiche WebLink
DATE 1/1912021 * * A M E N D M E N T Permit#S R o o s 2 5 5 2 1 EI Dorado Gas&Mart 1605 S El Dorado,Stockton,CA <br /> R E Eff I"V E D <br /> S A N. J O A Q U f N Environmental Health 0 �a ��i2� <br /> —C OU NIT Y----- <br /> TAW <br /> HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TA�K DI±RARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE, INDICATE PERM IT TYPE BELOW. <br /> la TANK RETROFIT D PIPING:REPAIRIRETROFIT LI UDC REPAIRIRETROFIT D MD$TAi1 R UPGRADE <br /> F EPA Site# Project Contact&Telephone# Lv� R 209-461-8337 <br /> Facility Name Phone# _ <br /> I Address 1605 S Ell DQrado St Stockton Ca 95205 <br /> L <br /> I Cross Street • Phone# 510224-6462 <br /> T <br /> Y OwnertOperator • Azl h r Phone# <br /> o Contractor Name _ r t 4 Phone# _ <br /> N Contractor AddressCA Lie# ����3 Class _ <br /> T <br /> A Insurer WeEmployerSU81 8n Work Camp# <br /> C. <br /> T ICC Techn'ician's Name Expiration Rate <br /> R <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (re.87 pfpinp Bump.91 leak selector.UDC 112,Cc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date (2"02,0 <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 /> HE 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 TAWS OF CALIFORNIA." C01VT R'S HERING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI THIS PE MIT 15 ISSUED,!SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicant's Signature Till. Date <br /> –'= LING INFORMATION: <br /> Indicate 1he respon ib party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below Is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> 4; <br /> NAME DebOCSh JoneS TITLE C)ffr'p ACSIStnnt PHONE# 209-461_6337 <br /> ADDRESS <br /> SIGNATUE DATE I119()9n <br /> 2Ofa <br />