Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 8 UDC REPAIR/RETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Chevron <br /> Phone# 209-465-3440 <br /> L Address 508 Charter Wa Stockton CA 95206 <br /> 1 Cross Street Lincoln <br /> T <br /> Y Owner/Operator Chevron <br /> Phone# 209-992-1735 <br /> D Contractor Name <br /> o Service Station Systems, Inc. Phone# 408-213-6038 <br /> N Contractor 680 Quinn Avenue CA Lie# 485184 ClaSSB C61/D40 HAZ <br /> Rusurer <br /> A Travelers Prop and Cas Work Comp# UB6054F2133 <br /> DICC Technician's Name <br /> p Robert Murdock Expiration Date 8/16/2013 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le sa PlPlno imp.s+wx ealec+m,uoc+rz,ex.1 Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions 1!1 Disapproved <br /> L <br /> q (See Attachment With Conditions) <br /> i <br /> N Plan Reviewers Name <br /> 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 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 TOBECOMESUBJECT <br /> TO 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 /> r <br /> Applicants Signwipner �r I,`k_ '.: �'•{ .� . ..,'�.1-�t, . -Title Compliance Officer Date ' �. ,� I �C l0L_ <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 Marty Weithman TITLE Compliance Officer PHDNE# )(408 213-6038 <br /> ADDRESS 680 Quinn Ave. San Jose,95112 <br /> 7( <br /> SIGNATURE 11 ( [� L; � �� - � f 'c i DATE 2/24/2012 <br /> EH230038(revised 02/20/09) <br /> 1 <br />