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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑PIPING REPAIR/RETROFIT I UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 1'�a� iE4Ar,tt(> L1 ,�(�_ Q(3- 1003 <br />A <br />G <br />Facility Name S QjfLCq� <br />Phone # <br />1 <br />Address 604-Qlk7 W, it+(A St. Tmc CA 10'1 Ir <br />T <br />Cross Street Cc* V A 4 0 W <br />Y <br />Owner/Operator.k .Ttxc (S�� c(-eM <br />Phone # <br />C <br />Contractor Name MAL <br />Phone # Zp`j .. S- <br />N <br />Address 3 ,)L a4 ` e f (o Lk�( {�( y. <br />CA Lic # ' �(� Class <br />A <br />Insurer Tu�SL� �� (� �k � � .�( ��{� <br />Work Comp # kLTL JObU 6C3�A <br />T <br />ICC Technician's Certification Number J Q -S-4 S( '� — u <br />Expiration Date 01-4 <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑App vedA ved with conditions ❑Disapproved <br />L <br />A <br />&tchment <br />SWith Conditions) <br />N <br />Plan Reviewers Name 661 <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO UIN COUNTY ORDINANCES, SMLAS, 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 />�& <br />&Applicants <br />Signature l <br />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 <br />s�ignnatur{e.anddate below. <br />NAMEh —TITLE I5_jUpL(eLL9_e 6-41-64-11 PHONE# K ( - <br />(co, <br />ADDRESS 6 t V ©U L!\V� / c �L Vb�Q CA 9 S l 0_ <br />SIGNATURE►-C��y�l-c-�x+�LI.L,L�1,�J <br />EH230038 (revised 12/31/07) <br />01 <br />