Laserfiche WebLink
0 9 <br /> SA N sIJ O A Q U I N Environmental Health Department <br /> — COUNTY <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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Western Food & Fuel Phone# <br /> I Address 3032 Waterloo Rd., Stockton CA 95205 <br /> T Cross Street Sutro Ave <br /> Y Owner/Operator I / Phone# 916 442-0076 <br /> C Contractor Name Nucleus Pump Services Phone# 916-382-4761 <br /> 0 <br /> N Contractor Address 601 1 st Ave., Suite B, Sacramento,CA 9581 CA Lic# 949066 Class A-B-D40 <br /> T <br /> A Insurer Wesco Insurance Company Work Comp# WWC3236024 <br /> T ICC Technician's Name Brian Roth ,i / Expiration Date 10/19/19 <br /> 0 <br /> R ICC Installer's Name Brian Roth / Expiration Date 10/19/19 <br /> Tank system work area Tank Size/ Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> i <br /> i <br /> P ❑ Approved / ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ! 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 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: "1 CERTIFY <br /> THAT IN THE PERFORMANCE 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 Contractor Date <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 <br /> Ronnie Lewis TITLE Contractor PHONE# 916-382-4761 <br /> ADDRESS 601 1 st Ave.,Suite B,Sacramento,CA 95818 <br /> SIGNATURE DATE 8/14/18 <br /> 2 of 6 <br />