Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> -- C O U N T Y --- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 EPA Site # Project Contact & Telephone # <br /> A209 . 910 . 9099 <br /> Facility Name ARCO Phone # <br /> L <br /> Address 6009 N EI Dorado St, Stockton , CA 95207 <br /> I Cross Street W Swain Rd <br /> T <br /> Y Owner/Operator Sean Murphy Phone # 916 . 997 . 4527 <br /> c Contractor Name IEC Services Phone # 916 . 993 . 6312 <br /> 0 <br /> T Contractor Address 4901 Warehouse Way , Sacramento , CA 95826 CA Lic # 1064168 Class <br /> n140 HAZR <br /> A Insurer Insurance Company of West Work Comp # WSA5034491 -04 <br /> TICC Technician 's Name Hayden Nunes Expiration Date 1 /7/23 <br /> oICC Installer's Name Hayden Nunes Expiration Date 1 /7/23 <br /> R <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 <br /> A No changes to tanks . <br /> N <br /> K <br /> P ❑ Approved XApproved with conditions ❑ Disapproved <br /> L Attachment With Conditions) <br /> N Plan Reviewers Name i -CL� DateP <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR CE 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 TO <br /> 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." <br /> Applicant's Signature Title Mgr Date 7/9/21 <br /> BILLING INFORMATION : <br /> Indicate the responsible 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 /> NAME <br /> John Baylis TITLE Mgr PHONE # 650 . 969 . 9616 <br /> ADDRESS 4901 Warehouse Way , Sacramento , CA 95826 <br /> 7/9/21 <br /> DATE <br /> SIGNATURE �LZ7�"'�' <br /> 2 of 6 <br />