Laserfiche WebLink
S <br /> ff, N# ; J O A O U IN <br /> Environmental Health Department <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIP NG 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 # Megan Mitchell <br /> � <br /> Facility Name Ca Gasoline Inc Phone # 925 -785 -2000 <br /> L Address 2115 W Yosemite Ave Manteca Ca 95337 <br /> I Cross Street <br /> T <br /> Y Owner/operator Annie Sandhu Phone # 925 - 785 -2000 <br /> C Contractor NamePhone # 209-461 -6337 <br /> 0Elite IV Contrartors <br /> N Contractor AddressCA Lic # 1001331 <br /> T Class _ HA <br /> A Insurer Midwest Em to ers CasualtyCompany Work Comp # BNUWC0133392 <br /> T ICC Technician 's Name Expiration Date <br /> T <br /> o <br /> R ICC 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 /> I< <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L ee Attachment With Conditions) <br /> Nr - l � ! /ZoI `� <br /> 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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> C. <br /> Applicant's Signature Tide Officp AgSistant Date � � I <br /> Or— <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 Megan Mitchell TITLE Office Assistant PHONE # 209=4Fi1 - 63 :J7 <br /> ADDRESS 2535 Wog ram Dr Stockton Ca 95205 <br /> SIGNATURE _DATE <br /> 61 <br /> 2 of 6 <br />