Laserfiche WebLink
OCT-25-2010 22:13 From: To:4683433 Paae:3112 <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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT Q COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ZMn -Sig 3 <br /> C Facility Name L 41&v% Phone# 2 1 <br /> L Address '40�-�1 a5�ml . <br /> I Cross Street a-oN WF_ <br /> Y Owner/Operator -FreLtjLeA( c�b0.r # - g I Lk-3-tZ[F <br /> D Contractor Name -µ- Phone# <br /> D Care (sEU a� vol-L <br /> N Contractor Address C> 5Fr CA Lie# � rj 7325 �CIa33 <br /> T �} <br /> Work Comp# <br /> n Insurer RO . p <br /> { C ICC Techr)ician's Name e tS e� (,IST ((� xpiration Date a Z3 1.Ot( <br /> a ICC Installer's Name Lt�- p�fi Expiration Date I ba �Lj <br /> bv n n e Tank system work area SZ5Z-415 u t Date UST <br /> G. Tank Size Chemicals Stored Currently Installed <br /> "%. (IE 87 Pang sumo.Bi leak dl 9 ',UDC 121,etc I <br /> 2-d T f LN 1 ea-8—QlciSIP l�L N Fe o.d <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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'. '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 TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. `I CERTIFY <br /> THAT IN THE PERFORMANCE­qf THE WOR I THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" �/ <br /> Appticenl'c Si nelu a at - Dale /49— ?3 - 16 <br /> BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. It the party designated below is different than the permit applicant, e.g. property owner,the party must acknowledge <br /> this responsibility for the billing by Signature and date below. <br /> p(p <br /> ( <br /> Lk 3:7-7-pNAMESFra�(-= N'� �TITLE OttN�rPHONE N <br /> „Lc aY <br /> ADDRESS <br /> SIGNATUR DATE <br /> EH230038 ed 07/22/10) <br /> 2 f} <br />