Laserfiche WebLink
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 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Phone#1c�1 -�j�A - nLIC <br /> I Address ' Cl>�o 20 <br /> L <br /> T Cross Street 1� 44 <br /> Y Owner/Operator L_0\,J O `5-rC Phone#L 05 --qS I <br /> C Contractor Name At_PrAp_ PTVOL 1l;50mSEZACFjS jUC Phone# -10i <br /> O <br /> T Contractor Address <br /> C) , F_o (��� Q�xl��-1 CA Lic# U 2 y �LgClass <br /> R <br /> A Insurer n2_0 Work Comp#DIU,-Z ► tWI,-7r�1 <br /> C <br /> T ICC Technician's Certification Number Expiration Date <br /> ° <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T CoUS�loS2 bs►5�J�5 2c) �� VZEek)I.A(Z Int E�at�ED <br /> A 3gL1fW'bllo5Z 155 CL-J—L) U1A2 I.IL ► <br /> K 3CjCCk:�51 SZ OSlSStd�� 1 Inc 2 !`fl <br /> 5q OW c;1.052W 0SI5SL4 ID X0 01 <br /> 3Gcxx�Stlr`�� x s ZD L I ESL <br /> P []Approved NApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 111LL1til L` NJ(tAy � Date tc I CIZ <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 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage 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 for the billing by signature and date below. p Q <br /> NAME �� !��ID1GVMSEY�ZI/�CCS� I.k)CTLE PHONE# ��' —� V CJ���U <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />