Laserfiche WebLink
SA N JOAQUIN Environmental Health Department <br /> LOUNTY <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name Hassan and Sons Energy Products Phone # 714 761 -5426 <br /> � Address 192 Lathrop Road <br /> I Cross Street <br /> T <br /> Y Owner/Operator Colonial Enegry , LLC Phone # 714 761 .5426 <br /> C Contractor Name Fueling and Services Technology Inc . Phone # 657 262-8195 <br /> T Contractor Address 7050 Village Dr Suite D , Buena Park 90621 CA Lic # 794519 ClassAHAZC21C10BC20 <br /> A InsurerLiberty Mutal Fire Insurance Company Work Comp # W. 14 7955030 <br /> c <br /> T ICC Technician 's Name Nicholas Milton 8882308 Expiration kqte 1 <br /> R ICC Installer's Name Nicholas Milton Expir o e /08/21 <br /> R <br /> Tank system work areaTank Size Chemica d rent) � Date ST <br /> (i e. 87 piping sump, 91 leak detector, UDC 112, etc.) , y1d <br /> T L� 1 <br /> N 8' 20K Petrolem �J <br /> K 91 20K Petrolem Q. <br /> Diesel 12K Petrolem <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S tta hment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name Date_ <br /> APPLICANT MUST PERFORM ALL W ,K ACCORDANCE WITH SAN JOAQUIN UNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS 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 WO F WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ^ Id <br /> Applicant's Signature Title �•idi Q Date �l <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 Becky Gallego TITLE Permitting Manager PHONE # 657 262- 8195 <br /> ADDRESS 7050 Village Dr Suite D , Buena Park 90621 <br /> SIGNATURE DATE2/9/21 <br /> 2 of 6 <br />