Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 MAF 13 2017 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT N PIPING REPAIR/RETROFIT IN UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name Loves Travel Stop <br />Phone # (209) 599-0740 <br />1 <br />Address 1553 West Colony Road <br />I <br />T <br />Cross Street Jack Tone Road <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name L.A. Perks Petroleum Specialists, Inc. <br />Phone # (775) 358-4403 <br />0 <br />N <br />T <br />Contractor Address 765 East Greg Street #103 Sparks, NV. 89431 CA Lic # 678948 Class A, C, HAZ <br />R <br />A <br />Insurer MMT Insurance <br />Work Comp # V1( 169920717 ,C 3 7/ <br />T <br />ICC Technician's Name RobertAlfers <br />Expiration Date 12/3/2018 <br />oICC <br />R <br />Installers Name Mike Koenig <br />' g <br />Expiration Dale 7/21/18 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc) <br />Installed <br />Diesel <br />20,000 <br />Existing <br />T <br />A <br />Diesel <br />20,000 <br />Existing <br />N <br />K <br />Regular <br />20,000 <br />Existing <br />Regular Unleaded / Premium Unleaded <br />12,000 / 8,000 <br />Existing <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date 2 % <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: "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 RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature / Title Director Date - : "O h1 <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 L.A. Perks Petroleum Specialists / Keith Perks TITLE Director PHONE # 775-358-4403 <br />765 E. Greg S�,S, NV <br />SIGNA <br />EH230038 (revised 10/30/12) <br />N <br />TE 1/16/17 <br />VA <br />