Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +------------------------------------------------------------------------------------------------ --------------- ---+ <br /> EPA SITE # : PROJECT CONTACT & TELEPHONE # <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> F ; FACILITY NAME ; PHONE # <br /> ' A +-----------------------------------------------------------------------------------------------------------------------------i <br /> C ; ADDRESS <br /> I +----------------------------------------------------------------------------------------------------------------------------' <br /> L ; CROSS STREET <br /> ' I +----------------------------------------------------------------------------------------------------------------------------' <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> --------------------------------------------------------------------------------------------------------------------------------- <br /> C ; CONTRACTOR NAME I PHONE # <br /> ' O +-----------------------------------------------------------------------------------------------------------------------------i <br /> N ; CONTRACTOR ADDRESS ; CA LIC # ; CLASS <br /> ' T +----------------------------------------------------------------------------------------------------------------------------' <br /> R ; INSURER : WORK.COMP.# <br /> A '------------------------------------------------------------------------------------+----------------------------------------' <br /> C OTHER INFORMATION <br /> ' T +-----------------------------------------------------------------------------------+----------------------------------------' <br /> 0 ; ; PHONE # <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK1 ID # 11 ' I �I TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED ' <br /> 39- <br /> T 39- <br /> A 39- <br /> N I 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L ; APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> ..„„.,,,,,,iii,ii��ii�iii�i�,i��ii,i���������i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> +------------------ ----------------------------------------------------------------------------------------- <br /> BILLING <br /> -----------------+BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />