Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 18 2016 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: DEPARTMENT <br />1�(TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # A & S Engineering Ahmad Ghaderi / 661-250-9300 <br />A <br />C <br />Facility Name <br />Phone # 661-250-9300 <br />1 <br />L <br />Address 401 West Kettleman, Lodi, CA 95240 <br />TCross <br />Street South Lee Ave <br />y <br />Owner/Operator Tesoro Refining & Marketing Company LLC <br />Phone # 210-626-6224 <br />C <br />O <br />Contractor Name Fuel Pros Inc. <br />Phone # 909-614-1379 <br />T <br />Contractor Address 14774 Central Ave, Chino, CA 91710 <br />CA Lic # 269354 Class A, C36, B <br />A <br />Insurer Midwest Employers Casualty Company <br />Work Comp # BNUWC0133329 <br />C <br />T <br />ICC Technician's Name Raul Vasquez <br />Expiration Date <br />p 12/9/2017 <br />Q <br />R <br />ICC Installer's Name Raul Vasquez <br />Expiration Date <br />p� 3/10/2018 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />Existing to Remain <br />A <br />N <br />K <br />P <br />❑ Approved 14JApproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />AIN <br />Plan Reviewers Name Date r/ <br />APPLICANT MUST PERFORM ALL WORK IN ACCO ANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH D ARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHIC HIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALI RNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE W FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />w /) <br />Applicant's Signature Title & VO ---Z. TE �7 Date L� �X lao I G <br />BILLING INFORMATION: <br />Indicate the responsiblparty 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 A & S Engineering TITLE Agent for Tesoro PHONE # 661-250-9300 <br />ADDRESS 28405 Sand Canyon Road Canyon Country CA 91387 <br />SIGNA <br />EH230038 (revised 07-17-2014) <br />2 <br />DA <br />