Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 DEC 0 7 2018 <br /> Telephone : (209) 468 - 3420 Fax : (209 ) 468 - 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANOVIRONNIENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTN >IENT <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 # Angel Rodriguez 916- 3734165 <br /> A <br /> C Facility Name Tesoro #68154 Phone # <br /> I Address <br /> L 2500 W . Lodi Ave. Lodi 95242 <br /> TCross Street <br /> Y Owner/Operator Tesoro Phone # <br /> ° Contractor Name Walton Engineering, Inc . <br /> ° Phone # 916- 373 - 1165 <br /> N <br /> T Contractor Address P . O . Box 1025 West Sacramento CA 95691 CA Lic # 617238 Class AB HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp # 9113339 -2019 <br /> °T ICC Technician ' s Name David Delgado - 5246959 Expiration Date <br /> 12-29 -2019 <br /> ° ICC Installer's Name Expiration Date <br /> R David Delgado - 5246959 p 9-24-2020 <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 — Replace drop tube . <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A e <br /> N Plan Reviewers Name foc Acc \ \( �-�X \� � Date � 1 "� r6�\ � <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 L SOF CALIFORNIA. " ONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY <br /> THAT IN THE PERFORMANCE THE WORK FOR WHI THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> P4 <br /> Applicant's Signature Title rY ) Date Z <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 <br /> �for <br /> rthe billing by signatureanddate below. <br /> NAME_ / IG�lil (il Lj � ) T "1 TITLE Phe. S PHONE # <br /> ADDRESS P . CJ , K I C725 W CSS J SG�G /� „ cM FO Jt I SCq l <br /> SIGNATURE DATE s <br /> EH230038 (revised 7-26-2016) 2 <br />