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 BELOW. <br />I TANK RETROFIT UPIPING REPAIR/RETROFIT LIUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name ,e v j-ar 44�Phone 9 <br />Address / /� (> eke <br />ICross <br />T <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />o <br />Contractor ne <br />Pho #�(�j 3 <br />T <br />Contra cqAdre - CA Lic # Class / C 16 M4 <br />AInsurer <br />Work Comp # <br />TICC <br />Technician's Certification Number Expiration Date <br />RICC <br />Installer's Certification Number" a� �� Ir Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />p <br />UApproved IlApproved with conditions UDisapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name laILA UA Date — -�;?x 10:1— <br />APPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACIUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAWN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR UC24SED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />FORMANCE OF WORK FOR Wt ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />SCOMPENSA LAWS OF CALIFORNIA" CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />�FN�HE <br />PERFOR OF THE WORK FOR WHICH THIS PERMIT IS , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CAURNIA" .�rl /{67 <br />of fN <br />ApplicartsSignatur 1 Title (� i!� Jute ,Maq C_7/YJ) <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 pa designated below is different than the permit appl' nt, e.g. property owner, the party must acknowledge this <br />respo [ billi nature and to below. 7? <br />" -t <br />NAM TITLEHNE #o <br />AnDRFSS�,;�/ '�M clvd"' <br />-- <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />1 <br />