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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> U TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Randy Brown 916-826-6828 <br /> C Facility Name PG&E Service Center Phone#209-337-8902 <br /> I <br /> L Address 4040 West Lane, Stockton, Ca. 95204 <br /> TCross Street Enterprise <br /> Y Owner/Operator PG&E Phone#209-337-8902 <br /> C Contractor Name Gettler-Ryan Inc Phone# 925-551-7555 <br /> 0 <br /> N Contractor Address 6747 Sierra Court Suite J, Dublin, CA. 94568 CA Lic# 220793 Class Attached <br /> T <br /> R <br /> A IInsurerAcord Work Comp#DTJUB7827P41511 <br /> C <br /> T ICC Technician's Name Mike Pratt Expiration Date May 26, 2013 <br /> 0R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detector,UDC 112,etc.) Installed <br /> T 87 fill sump Veeder Root sump sensor unknown 87 gas unknown <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (See Aft hment With Conditions) <br /> A <br /> N Plan Reviewers Na 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 TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE SOEJW WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's ignat re Title Service Manager Date February 28, 2012 <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 acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME Randy Brown TITLE Service Manager PHONE# 916-826-6828 <br /> ADDRESS 6747 Sierra Court Suite J, Dublin, Ca. 94568 <br /> SIGNATU DATE February 28, 2012 <br /> EH230038(revised 07/22/10) <br /> 2 <br />