Laserfiche WebLink
RECEIVED <br /> SANJOAQUIN Environmental Health department <br /> -- c o U I\I T Y - --- AUG IT <br /> a Z <br /> APPLICATION FOR UNDERGROUND STORAGLE ?OXWNMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT D PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Janelle Dockham <br /> A <br /> C Facility Name YRC , Inc . Phone # <br /> 209.833 . 1408 <br /> I <br /> L Address 1535 E . Pescadero Avenue <br /> I Cross Street North McArthur Drive <br /> T <br /> Y Owner/Operator YRC Phone # 209-833- 1408 <br /> o Contractor Nwestco LLC Phone 661 -631 -3870 <br /> T Contractor Address 2209 Zeus Court ICA Lic # 1073967 Class A Haz <br /> A Insurer Ohio Casualty Insurance Company Work Comp # XWS57384241 <br /> c ' <br /> ICC Technicians Name Terrence Lay Y Expiration Dale <br /> R 03118193 <br /> ICC Installer's Name <br /> Terrence La Expiration Date 03/18/23 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> p.e, 87 piping sump, 91 teak doloclor, UDC 1R, olc,) y Installed <br /> T Tank 6 61000 Waste Oil <br /> A <br /> N <br /> K <br /> P ❑ Approved Q Approved with conditions ❑ Disapproved <br /> L n (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date U <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 01 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 /> ORKER'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 15 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' �� <br /> Applicanrs Signature Z/610 Title Permit Clprk Dalo OR/15/2027 <br /> 01 <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 sign t}�e and date below. <br /> NAME INS )J2� 1 r IT 1 �6 ml �1 lfi C� PHONE <br /> ADDRESS W /9 Q\ /I &CI S4LajC� <br /> SIGNATURE DATE <br /> r �� cl � 1251 X122 <br /> tots; <br />