Laserfiche WebLink
SANJOAQUIN Environmental Health Departmelit n l ' <br /> -- COUNTY -- �1 �t ; `% F:k <br /> APPLICATION FOR UNDERGROUND STORAGE TANK AUG `' 1 2019 <br /> RETROFIT OR PIPING REPAIR PERMIT gplIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BEL &p ;SENT <br /> N TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EV <br /> F EPA Site # CAD981390073 Project Contact & Telephone # 916 -224- 7280 <br /> APhone # <br /> C Facility Name Pacific Gas & Electric <br /> I <br /> L Address 4040 West Lane, Stockton <br /> TCross Street Enterprise Street <br /> Y Owner/Operator Pacific Gas & Electric Phone # 209 - 561 - 7163 <br /> C Contractor Name TAIT Environmental Services, Inc. Phone # 916 - 858 - 1852 <br /> O <br /> N Contractor Address 11280 Trade Center Drive, Rancho Cordova, 95742 CA Lic # 588098 Class A,B,C10 , HAZ <br /> T <br /> R <br /> A Insurer See attached Work Comp # See attached <br /> C <br /> T ICC Technician's Name See attached Expiration Date <br /> RICC Installer's Name See attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> Waste Oil tank / Spill bucket 1000 gal Waste Oil 01 -014998 <br /> T <br /> A <br /> N <br /> K <br /> P _ .� Approved Approved with conditions Ll Disapproved <br /> L ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date��T� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD%XNdE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH 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 SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERF R7 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /�/] / <br /> Applicant's Signature Title A jk Date 1 <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 <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Kristin Reynolds TITLE Project Manager PHONE # 916 -6694852 <br /> ADDRESS 11280 Trade rater Drive , Rancho Cordova, CA. 95742 Q <br /> SIGNATURE DATE ' 1 <br /> 2of6 <br />