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 /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ®(UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Michelle Le 209-602-7038 <br /> C FacilityName PG&E Stockton Service Center <br /> Phone# <br /> I <br /> L Address 4040 West Lane Stockton CA <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> 0 Contractor Name Armour Petroleum Service & Equip . Co Shone# 707-437-6668 <br /> 0 <br /> N Contractor AddressPO BOX 507 Vacaville CA 95696 CALic# 498721 ClassA HAZ C10 <br /> T <br /> R Insurer Lincoln General Work Comp# cwc00058501 <br /> A <br /> T ICC Technician's Name Jacob Armour Expiration July 26 2009 <br /> o <br /> R 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 12.at.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Nam Date /vii <br /> APPLICANT MUST PERFORM ALL 4RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT. ER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THAPER I ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CAL O 1 NT ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF TH WOR THI PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ,� <br /> s SigneWro e C O n r .—Date — <br /> 20-09 <br /> ApplicanrBILLI 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 Michael A. Armour TITLEPreSident PHONE# 707-437-6668 <br /> ADDRESS PO Box 507 - XagavyfVe CA 95696-0507 DATE 4—2 0—0 9 <br /> EH230038(re sed 02120/09) <br /> 1 <br />