Laserfiche WebLink
08/22/2006 12:55 9094767114 SHIRLEY ENVIRONMENTL PAGE 62/04 <br />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 PERMJT EXPIRES 90 DAYS FRCM TFE APPROVAL DATE, INDICATE PERMIT TYPE BELOW <br />❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT -1UOC REPAIR/RETROET <br />FEPA <br />A <br />Site # Project Contact & Telephone # <br />a,s 41d- 27-� <br />C <br />Facility Name ��sy/ ^^ ,� Phone# <br />L0. <br />Address 3 f s f Pa s f a-q��ir C, i}yt- <br />TCross <br />Streot <br />Y <br />Owner/Operator oe L , .4"t � � Phone* 9i7 - 1 VV- 7.4,4K <br />Contractor NameS',(„i/.r �� �r ,�, a Phone#APO-S 7o <br />T <br />Contractor Address Lvc.r ,(�,��„��( �F� CA Lic# �iyp.2% Class .4 <br />A <br />Insurer F /o L{�r / L� S4 -OL Work Comp 4f eA"e <br />G <br />T <br />ICC technician's Certificatlon Number _ Expiration Date <br />A //_ 20- d-/ <br />R <br />ICC Installers Certification Number g�. y d/ 7 _ k r- Expiration Date 7 L_,2 _,q <br />Tank ID # <br />Tank Size <br />Chemlcals Stored <br />Currently/Previously <br />Date UST Installed <br />r <br />L 7t/a �c U <br />o0o <br />u/r LD, <br />fA AL <br />A <br />N <br />K <br />P <br />-Approved pproved with conditions DDlsappmved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />f <br />Plan Reviewers Name�• ,V �A Data 1cl- o <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGS '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 70 BECOME SUBJECTTO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE POLLOWING! "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br />OF CALIFORNIA" <br />APollumt, SlgnaMe Otte <br />M <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment ooveraca 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,W1he kjZp-py sign�tvre and date below, <br />ADDRESS Srr L < < .rs X.o-i.P 12 d "#/O sir as. e-4.Com- 9/2.?/ <br />EH230038 (revised 818/08) <br />