Laserfiche WebLink
ORIGINAL <br /> Q <br /> ENVIRONMENTAL HEALTH DEPART <br /> SAN JOAQUIN COUNTY %4EIVEL) <br /> 600 East Main Street, Stockton, California 95202 AUG 2 7 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPINGTTL, <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> I� TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name 99 Shell Phone# 209 957-5398 <br /> 1 Address 7700 Moreland Ct Stockton 95212 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Balaji Angle Phone# 209 957-5398 <br /> o Contractor Name Service Station Testing- SST INC Phone# (209)465-5577 <br /> N Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# 962520 Class A/B/C-1 0,2o,3s <br /> T <br /> R Insurer EXEMPT Work Comp# <br /> A N/A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/09/2016 <br /> o <br /> R ICC Installer's Name N/A Expiration Date N/A <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 /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved 14Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A _ 2� 2 <br /> N Plan Reviewers Name � f (- Date yr J I S <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 OF THE WORK F R WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." //�1' / / <br /> Applicant's Signature) �..fl ' ` Title Authorized Agent Date 8/27/15 <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 /> respo <br /> NAM SEE ATTACHED PHONE# (209)467-7573 <br /> ADDR SR0072975 <br /> SIGN dated 8-26'15 DATE 8/27/15 <br /> EH2300 revtse <br /> 1 <br />