Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY JAN 2 2 20`` <br /> 600 East Main Street, Stockton, California 95202 EKM1-1 NN!F-IN sAL <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> :fit`:L, <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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameCHEVRON SS#9-9840 Phone# 925.842-1000 <br /> 1 Address 4344 WATERLOO ROAD <br /> L <br /> I Cross street PICCOLI ROAD <br /> T <br /> Y Owner/Operator CHEVRON PRODUCTS COMPANY Phone# (925) 842-1000 <br /> o Contractor NameWAYNE PERRY, INC. Phone# (916)646-9680 <br /> T Contractor Address 30 MAIN AVE.SUITE 5,SACRAMENTO,CA.95838 CA Lic# 300345 CIasSA,B,C10,C-61/D40,HAZ, <br /> A Insurer TRAVELERS PROP & CASUALTY CO. OF AMERICA work Comp# 10000019610 <br /> T ICC Technician's Name BRANDON SMITH UST INSTALL Expiration Date 5/30/2016 <br /> R ICC Installer's Name BRANDON SMITH UST SERVICE Expiration Date 5/30/2016 <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 PREMIUM UNLEADED 15,000 91 GASOLINE <br /> A <br /> N <br /> K REGULAR UNLEADED 20,000 87 GASOLINE <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ,J <br /> h/I(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 <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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature �� Title AGENT FOR OWNER Date <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 /> responsibility for the billing by signature and date below. <br /> NAME Liddy McKenzie TITLE Project Manaqer PHONE 4925.551.7555 <br /> ADDREss6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br /> SIGNATURE DATE /h.//-ZL''�� <br /> EH230038(revised 02/20/091)" <br /> 1 <br />