Laserfiche WebLink
®002/005 <br /> 08/06/2008 WED 14: 54 FAX <br /> 07/02/2008 WED 15: 06 FAX 20 3433 SJC EED 01004/005 <br /> 07/02/2008 WE'D 12t13 FAX 0002/004 <br /> i 07/02/2008 WED 11:57 FAX 205 '3433 STC SED ®002/004 <br /> t <br /> j ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY C►?e'.:�sed) <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (Z09)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS GTANK ReTROFrrRMIT EXPIRES G REPA RIRETROFITISO DAYS FROM THE APPROVC;UDC REPAIR/RETROFIT ITTYPE a COOLD$TART/EVR UPGRADE <br /> f EPA Site# _ ... _Proiecl Contact''&Telephone# <br /> . ...... <br /> 1--I --�— FacilityNsma `I6. <br /> ! Address L(. , ` ,� CA. <br /> T Cross Street <br /> ' Y Owner/Cperator� Phone# <br /> o Contractor Name Phone# . 970- . f1$O <br /> 0 <br /> I 7 Contractor Atltlress _ I 4.Aa0( P.n, f r�+[vaAany� CA Li c# 89-1 Class <br /> R <br /> insurer L,6exr s,. CA Work Cow# LOA*T>'D00-f 177 /7 <br /> T ICC Technic(an's CerOficaWn Number S_ti S t, Q)4kTIA . YAe tL j6WExpira0on Date S,&,L,L q-jW <br /> ` R ICC Installer's Certification Number ll l u Expiration Date al <br /> Tank ID ti Tank Siza Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> .. . ....... .. ......•..iP.:.: <br /> FA <br /> ._....... .... ..... ... ._._..__.. <br /> IDApproved _Approved With Conditions �_�Dlsapproved <br /> (See Attachment With Conditions) <br /> ¢rS Name ry c— Date G ?' 7 <br /> APPLICANT MUST PERFORM <br /> """"'-""'"-`JD'At5L11N COUNYY;ENVIR'ONMAL€LNTWAQIBK W,AMNEWH_ ... ODINANCES,SSWFSAN..GA , A <br /> HEALTH DEPARTMENT. ...._........._. <br /> OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OP THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALT.NOT EMPLOYANY PERSON IN SUCN A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING OR SUSCONTRACT(NO SIGNATURE CERTIFIES THE FOLLOWING; "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED.f SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> APp'kanla Sl4natwB Title i- -Y Gale / �'V'n <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 e bllllng � �lure and data below.ITLE ElifM�➢"r�_ /� �j <br /> ffYY p� �,,,,. 'QLf01-�4�oG' PHONE 11�t1/(�1 l�'�'�Q�� <br /> ADDRESS 251 jE Vt`YL �-f dfao AV IjZ W Ske—a •A/)T�:n CA _ <br /> SIGNATURE <br /> qs�q M <br /> EF x=$a(revised 12131/07) <br /> _......___.__._...__...__...................................._..__..._._....___..:..__..____._.__._.._._.....__.___..._.___....:_......._.__...---...fK� <br /> s J <br />