Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE�BBELOW: <br /> ❑TANK RETROFIT ❑ PE� <br /> PIPING REPAIR/RETROFIT L 9UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# h lee r)ge rtchu.cJ 9zs=%'Z4ka <br /> � Facility Name ChevroyiS4-a,-hog'` Phone# LPg_ <br /> IL Address s0o {44A.C14r4Aar <br /> / <br /> ICross Street 1 -ZO J <br /> T <br /> Y Owner/Operator k,,qrq yr✓ //T q Phone# 7 Ury-8/y� �Sg <br /> C Contractor Name e 4rti/ e- (<e%(/YL /n _4celta/IL Phone ZS-LffpZ-L/ le Z) <br /> N Contractor Address '7(p (,(f Ornljt 'f'. � PQ /j/7 pYL FCA 7 /IV? Classe/'j/ -/J 1/D <br /> A Insurer lQ (eh-kur uranc� Work Comp# A- /9ra�/S� <br /> T ICC Technician's Certification Number Expiration Date •Z m 7p <br /> D <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved (N.4pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name mc_� 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 /> Applicants 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. //� /��� ��GJ <br /> NAME t�Q/YI/7//-N-/Al/I Pi��/10 tf �— TITLE /t-��• C A PFIO1N/E# 7Z�1 -7lO Z-�OG� <br /> ADDRESS r ! r! ✓" 0Y)4 L 12 c)�' QAC d Cl h'IV'I <br /> SIGNATURE <br /> EH230038(revised 8/8/08) <br /> 1 <br />