Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468 - 3420 Fax : (209) 468-3433 <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 /> O TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> C Facility Name Tracy 76 Phone # 209-830- 1139 <br /> L Address 2420 W. Grant Line Rd Tracy , CA 95377 <br /> TCross Street <br /> Y Owner/operator Gills Fuels Incorporated Phone # 209-830- 1139 <br /> C0 Ed <br /> contractor Name ElitelV Contractors Phone # 209-461 -6337 <br /> T Contractor Address 2535 Wigwam Dr. Stockton CA 95205 CA Lic # 1001331 Class A" HAZ <br /> A Insurer Midwest Employers Casualty Company work comp # BNUWC 0133392 <br /> T ICC Technician' s Name Chris Adams 8230218 Expiration Date 4/17/2020 <br /> RICC Installer's Name Expiration Date <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 /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <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: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK F WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 0 / ) <br /> Applicant's Signature Title Service Coordinator Date 06 -21 -2019 <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 Olivia Marie Ojeda TITLESeyice COorinator PHONE # 209-461 -6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton , CA 95205 <br /> SIGNATUREDATE 06-21 -2019 <br /> EH230038 (revis 2-11 -15) 2 <br />