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from: 0210"9012 15:01 #725 P.001 /001 <br /> ENVIRONMENTAL HEALTH DEPARTMENTA12 <br /> SAN JOAQUIN COUNTY ,JLJ/YLl1,le•J+,I It�I�! <br /> 600 East Main Street, Stockton, California 95202tiI%IVItw;C14MLihi'1AL <br /> '.r'.A I-rLJ r,.mo 3--AAr- tl <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 - _ . <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 /> L7 TANK RETROFIT 0 PIPING REPAIR/RETROFIT d UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA site# Project contact&TelepArodrew Rehberg 209-649-8171 <br /> G Facility Name DBA: River Point Landing Marina Resort Phone09-951-4144 <br /> ddress 4950 BucIloy Cove Way, Stockton CA 95219 <br /> I Cross Street <br /> T W. March Lane <br /> _ <br /> Y Owner/Operator Andrew Rehberg <br /> - Phone#209-951-4144 <br /> C Contractor Name _ <br /> D Phon <br /> N Contractor Address CA Lic# -Class RA HA7 <br /> T 4475 Yank -P <br /> RInsurer <br /> A Travelers Property Casualty Co. Work Comp# UB8239X433TIL11 <br /> C ICC Technician's Name Steve Richardson #5262233 5-12-2013 <br /> T Expiration Date <br /> dCC Installer's Name eveRichardson <br /> R Expiration Date <br /> *"�nk system work areaDate UST <br /> u.8i piping sump,91 leak detector,UCC 112,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T 89 12K Gasoline Unknown <br /> A Diesel 5K Diesel Unknown <br /> N <br /> K <br /> P ❑ Approved Approved with conditions L-1 Disapproved <br /> L S e A hment With Conditions) <br /> A <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK)KACCOROANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL I..IE`ALTH 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 SU9JECT TO <br /> •ORKER'S COMPENSATION LAWS OF CALIFO l .- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> IHAT tN THE PERFORMANCE OF THE ORK FOR HICH THIS PERM17 IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF:CALIFORNIA.' ^� 1 <br /> Applicants Signature —Title— !{T%✓1 ✓l�Y� Da1B G " <br /> E'-LING INt'ORMATION: <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 .teff Scott TITLE- Estimator PHONE# 916-624-1985 <br /> ADDRESS 447 <br /> SIGNATLIRE DATE 02-02-12 <br /> EH230038{revised 11111) <br /> 2 <br />