Laserfiche WebLink
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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE LOW: <br />LJTANK RETROFIT UPIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT <br />F <br />EPA Site # Project Contact 8 Telephone # S i I Cz d iI 9S(. ,5-22, S I 10 <br />� <br />Facility Name E LLZW f TZG 146IJT Fphone # Ze)q . "63,3 - 13 0 0 <br />I <br />L <br />Address IL35 S • -;�EscA,DE.2co Avf <br />ICross <br />T <br />Street <br />Y <br />Owner/Operator (;NfLAS µLoy <br />Phone# Z09- cd33.13ae <br />o <br />Contractor Name ^('/11 AL TEk I <br />Phone # 01 S I . SZ2 • S11 <br />T <br />Contractor Address �p'� E LN I (L,(1 R.(S CA Lic # O 3'4 DS Class <br />A <br />Insurer STff —IE'F•J,4 +) <br />"brk Comp # S-41-000017-0 <br />TICC <br />7 <br />Technician's Certification Number SZS Z*31 <br />Expiration Date 5-()< <br />0 <br />ICC Installer's Certification Number 97 5-23 [::f <br />Expiration Data S1 0 <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Dais UST Installed <br />T <br />7 3 989 SVHP t"."rK <br />A <br />N <br />K <br />P <br />UApproved LJApproved with conditions UDisapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORV ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUINCOUNTY, ENVI MENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATI WS !)F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN TFE PERFORM THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CAUFORNIA" ` <br />Applicants Si0na0.re Title Ii'OWT 10tyellZ Date 1 Z/S <br />BILLING INFORMATION: <br />Indicate the responsible pag to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the parry 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. <br />Alm <br />tFu rH <br />EH230038 (revised 8/3!07) <br />tic 13 - Is <br />rt PHONE# "ISI' SZL- S1 I0 <br />J1_,n.SIDE. ILA, gLSocj <br />