Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 SCP 1 5 2016 <br /> Telephone: (209) 468-3420 Fax: (209) 468-343:tNVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# V PLProject Contact&Telephone# s,16, q0 <br /> Facility Name _ Phone# 0 / 5 <br /> � Address yj (o <br /> Cross Street �RI <br /> T 1114 <br /> Y Owner/Operator pL ADO. Cr— /5— <br /> C <br /> c Contractor P Phone#02* 5-37 3 <br /> O p <br /> T Contractor Address CA Lic# 009 Class <br /> R Insurer G6� d� S Work Comp# p <br /> A <br /> CL <br /> D ICC Technician's Name <br /> T Expiration Date <br /> D ICC Installer's Name ( ,L GC) - Expiration Date S -6-09)17 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le,87 piping sump,91/leak detector, <br /> ,UDC <br /> _112`,etc.) � 1 c� Installed <br /> T C-ASC % -- C' EEr) V L El✓ <br /> N S�$5 6 ono ��G E 00 E <br /> K E- <br /> -SV-L-P n Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 9 /.20 1 06 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUN 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.' - Q ' / <br /> Appliranrs Signatu Title Date /'��`I —/ <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. / +1,�(� p+�o <br /> NAME\�?m-n e W. TITLE l Y(-VP CTO PHONE ito.[.1iJ 7 SL 7 J <br /> ADDRESS r S7 - <br /> � / <br /> SIGNATURE r 9-f4-16.DATE %—f T�(-1b <br /> EH230038(revised 7-26-2016) 2 <br />