Laserfiche WebLink
12/02/2008 14:41 FAX 9163712540 BZMAINT f7J 001 <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 /> THIS PERMIT EXPIRES lee DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> rr <br /> LJII II PIPING REPNR/RETROFIT ITANK RETROFIT IUDC REPNRMPTROFIT COLO STARTIEVR UPGRADE <br /> FJ <br /> UDC <br /> Site# Project Contact&Telephone# <br /> A � P/Yl Phone# Z-og-9�/8 <br /> C Facility Name A 017Z <br /> L <br /> Addreas HA $ S S060, <br /> TCross Street Phone# 1-6 S <br /> Y Owner/Operator ✓/V7ESH /LL <br /> ft7 Phone# - ' •. �' . <br /> C Contractor Name j'"- <br /> O � Class <br /> N CA Lie# <br /> T Contractor Address �C ! �• <br /> R Work Comp# <br /> Insurer <br /> A Expiration Date <br /> D <br /> T ICC Technician's Certification Number <br /> Expiration Data <br /> o <br /> R ICC Installers Certification Number <br /> Tank Size Chemicals Stored Date UST Installed <br /> Tank ID# Currently/Previously <br /> C 00 D Q n'S f <br /> K K 3 <br /> P <br /> ❑Approved UApproved with Conditions F]Oisapproved <br /> L (See Attachment Wlth Conditions) D <br /> A <br /> N Date <br /> Plan Reviewers Name <br /> gpPUCANr MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSER AGENTS SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br /> WORKER'S COMPENSATE HE WORK FOR LAWS OF CALIFORNIA.ICH S'PERMIT OWRACTOR 6DHIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOI SHAUL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO B OWING: CERTIFY <br /> THAT IN TH5.pERFORMA OF THE ORK FOR I THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONA SU9JECT/.T/Op WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" /.IN�G D�10 s <br /> Appliwrde Slenetun Title L4 <br /> BILLING INFORMATION: <br /> Ina l ate the respo ible party to be billed for additional EHD staff time expanded beyonda hpyment yageprtank, If <br /> the party design ed below Is different than the permit applicant, eg• Property owner, mustacknowledge thiresponsibility for I billing by signature and date below. Q�nN 1D �7jJ,Js <br /> NAME <br /> (j>�S�( /G` TITLE. PHONE f_ O 77 <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 1213, 7 <br /> 1 <br />