Laserfiche WebLink
SANJOAQUIN Environmental HealthDeartm / t� <br /> COUNTYH � � <br /> APPLICATION FOR UNDERGROUND STORAGE TANK MAR 0 8 2019 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM T�QPPROVAL DATE. INDICATE PERMIT TYPE BE <br /> �j 1RONME (�! TAL HEALTH <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT L✓ IUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE `� T <br /> F EPA Site # Project Contact & Telephone # KARLI KARNS (661 ) 631 -3870 <br /> A <br /> C Facility Name FLAG CITY CHEVRON Phone # 925-464-3635 <br /> I <br /> L Address 6421 CAPITOL AVENUE <br /> I Cross Street PENNANT DRIVE <br /> T <br /> Y Owner/OperatorAZAD AMIRI Phone # 925-464-3635 <br /> C Contractor Name CONFIDENCE UST SERVICES , INC . Phone # 661 -631 -3870 <br /> 0 <br /> N Contractor Address 16250 MEACHAM ROAD , BAKERSFIELD , CA 93314 CA Lic # 804904 Class HAZ A, C61 -D40 <br /> T <br /> R <br /> A Insurer STATE FUND Work Comp # 1308317-2018 <br /> T ICC Technician 's Name FRANK LANDA Expiration Date 01 /28/2021 <br /> R ICC Installer's Name FRANK LANDA Expiration Date 11 /06/2019 <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 UDC 1 /2 <br /> A UDC 3/4 <br /> N <br /> K UDC 5/6 <br /> UDC 7/8 <br /> UDC 9/10 <br /> UDC 11 /12 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers NameLa 1 V �(� � Date J 1 <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 FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �/ <br /> Applicant's Signature �, la446; a&OtJZZ� Title DISPATCH COORDINATOR Date 03/05/2019 <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 KARU KARNS TITLE DISPATCH COORDINATOR PHONE # 661 -631 -3870 <br /> ADDRESS 16250 MEACHAM ROAD , BAKERSFIELD , CA 93314 <br /> SIGNATURE l �a&oz4d� DATE <br /> 2 of 6 <br />