Laserfiche WebLink
03/11/2008 TUE 7: 39 PAX 209 3433 SSC EHD 1@003/007 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> I� <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> DTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRMETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# {ZIGtl 6.%cv%c7T' 921 '1�0•�l•19.3 <br /> � <br /> Facility Name � IR�J Phone#�951)2-tC - 5153 <br /> L Address �lo211p GL1Y�1C31� 1��3T t� M �lS o <br /> I <br /> T Cross Street 1,,,p�)lSt Lav G <br /> Y Owner/Operator G Phone#(gSl Z.'1 C -S V�'13 <br /> C Contractor Name FU�Uyt ICES 41 Phone# rj2 - pL9`I <br /> N Contractor Address U c-,p �( p(j p5ijr-1JA PL< CA LJc# 7 T4s( class A l Az- <br /> A Insurer V-r—P A?OOb INS. GP Work Comp# W'l (`p'L(.1tg <br /> T ICC Technician's Certfication Number $O dT Expiration Date F&* Icq <br /> R ICC Installer's Certification Number 5)�3 poe 8p U1 Expiration Date OV, 10Q, <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 1 /2 !� /z <br /> N 2 12 r I�EhI. <br /> K <br /> P ❑Approved BApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A M <br /> N Plan Reviewers Name &Irti Date 511-2-1 0 b <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE V40RK 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 CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANC THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' `.r <br /> ApplitlnN Signature 7Ne [S� DeOe <br /> ILLING INFORNIAT ON: <br /> Indicate the r sponsi party to be bill for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designet 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. <br /> NAME I2tC-" TITLE FIR-) Mt461j lZ PHONEkc: ✓11 271 C-1 9S <br /> ADDRESS 1 / S_C 4f,47V-o rJ6 Z ib-I <br /> SIGNATURE - <br /> EH230038(revised 12/31/07) <br /> 1 <br />