Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUN 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 <br />If BELOW" <br />UTANK RETROFIT UPIPiNG REPALR/RETROFIT I dIDC RFPA1R/RFMCjRT <br />F <br />A <br />I EPA si>E # Pre�t Contact 8 Teleptwne # a o9 ' y(P� -6, 33 � 6a.1I: <br />C <br />Facility Nameoil-fArtn # togs -Phone #- _ 6 <br />I <br />L�� <br />Address <br />I <br />Cross Street <br />T <br />yOwner/Operator <br />4-0-W 'e -CCL 11 C� (' <br />Phone# _Sa-j)r„— <br />O <br />Contractor Name t V <br />lPhone #;b/ q- &!- X33 <br />T <br />Contractor AddressCA Uc # Lp LoOO -7 rp t p I. <br />L YYrn 7 r <br />R <br />Insurer - c�if1 r work Comp # <br />T <br />IGC Technician's Certification Numberr.; ^a ((_ � <br />`t s%% — " Expiration, Data � <br />, <br />R <br />ICC Installer's Certification Number Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />u <br />K <br />P <br />LlAppro proved with conditions UDisapproved <br />LOSee <br />A <br />Attachment With Conditions) /7 <br />N <br />� / <br />Plan Reviewers Name i f �/�V ��� <br />Date <br />APPLICANT lRL1S7 F'ERFOi?!aI AU WORK LCL A ANI E VATH.SAN JOAQM .. OREMA Y;ES, STATE LAM ANR R1 I AND. <br />.HOAC AN COLROY, ENVIRONMENTAL HEALTH 11EI-ARTMENT. OWNER OR LPC84SED AGENTS SIGNATURE CSMFIES THE FOLLOVAN3: CBMFY THAT W <br />HE <br />THE PERFORMANCE OF T"GRK FOR WHICH THIS PERMIT IS ISSNSHALL , I L NOT EMPLOY ANY PERSON W A <br />SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORMUL' CONTRACTORS H IRMOR SUBCONTRACTING SKiNATURE CER1VIES THE FOUDVANa '1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHK;H THIS PERMIT IS ISSN, I SHALL EMPLOY PERSONS SUBJECT TO MW.Srs COMPEIISATION LAWS <br />OF CJWFORMA" <br />BIWNG INFORMATION: <br />Indicate the responsible party to be billed for additional END staff fine 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 acbmwiedge this <br />responsibility fo/r the billing by' Jsignature and <br />�date <br />/below. / <br />NAME rLl T f f V !?"ft -,-c iV jTITLE PHONE *do V - V61- 6337 <br />EH23DO38 (revised =M) <br />Nr <br />