Laserfiche WebLink
r-NVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />Ll TANK RETROFIT F1 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # 9189 <br />Project Contact & Telephone # <br />D <br />Facility Name -�TPGlc I I-1 +i a133 x <br />Phone# <br />I <br />L <br />Address 0 6 5 8- � w s� O �i(� �dy� CA a 5 ZA (D <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # Z01 -X152. 221 <br />D <br />0 <br />Contractor Name �ctJOLo <br />Phone # to <br />%�rI`� S-l7�-a f0 <br />T <br />Contractor Address d �� o4 5'3vo CA Lic # -7 q 3 b O Class <br />Rsurer <br />A <br />In�/Lr.Nt(, Cr4g+AL Crr�.pan <br />Work Comp # <br />D <br />T <br />ICC Technician's Name ,� 'C. nn O V5915L( -W? <br />Expiration Date I -11_ zaV� <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />_ . -- <br />A <br />N <br />- - <br />K <br />n Approved Approved with conditions n Disapproved <br />P <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WO IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 <br />TO 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 Title Date <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 />NAM <br />SIGNATURE _ <br />EH230038 (revised 02/20/09) <br />TITLE PHONE #, <br />1 <br />