Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBERE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> +--- ----------------------------- --- - -------------------------------- -+ <br /> EPA SITE # ; PROJECT CONTACT & TELEPHONE # Scott POlston 925 551-7555 <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> F ; FACILITY NAME Fremont Arco ; PHONE # 925 551.7555 <br /> --- ---------------- ----------------------------- <br /> C I ADDRESS 1617 West Fremont Street <br /> I +— ----- ------- --- --- -------------------------------- <br /> L ; CROSS STREET North Pershing Ave. <br /> ----- ------ --------- <br /> T OWNER/OPERATOR PHONE # <br /> Y Fremont Arco (209)462-1617 <br /> '---+--------------------------- -----+------------------------- - <br /> C CONTRACTOR NAME Gettler Ryan Inc. IPHONE #925 551-7555 <br /> 0 +---------------------------- <br /> - --------------------- - <br /> N CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin CA LIC # 220793 CLASS a,b,C-10,haZ,c57,c61,d40 <br /> T +- ---- <br /> —-------------------- ----- --- -- <br /> R INSURER State Fund I WORK.COMP.# 426-2004 <br /> A ,________________________________________________ <br /> C OTHER INFORMATION <br /> T +---------------------- ---- ---- --_--------- —+- ---------- <br /> _-_------ <br /> 0 ' PHONE # 925 551-7555 <br /> --- -----------+----------------- ------ <br /> PHONE # <br /> +--- „ <br /> ----------------------------------- ---------------------------------------------------------- <br /> TANK <br /> -- --------------------------- -TANK ID # <br /> TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A SS,E�E,p/T�T�ACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME I I i�.V� �!/V`GLVa DATE Id <br /> TOL <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSA ION <br /> LAWS OF CALIFORNIA." CONTRACT S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE RFORMANCE .9F THE WORK FOR WHI T S PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF C FORNIA." / <br /> APPLICANT'S SIGNATURE: /^� TITLE Permit Expeditor DATE 4-A <br /> ------------------------------------ ---------- ----- ---- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6747 Sierra Court,Suite J <br /> Name $COtt PO OnA Dubsasses Phone # 925 551-7555 <br /> Signatur <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />