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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#60C 7 293 L9��O <br /> A <br /> C Facility Name U54 �laglPhone# <br /> � Address c?,qW etlaE k� AAj L~ uo/ C� <br /> T Cross Street tOCAIeZ AaZgMf.*Jp )90?W <br /> Y Owner/Operator Z eX& ��tilti�- fi Phone# <br /> C Contractor Name > Phone# <br /> o /�'1✓�iV 7�7 � <br /> N #Lic CA Contractor Address Class <br /> T l7r� / ' ,. �9i.�l i/ t�12 <br /> A Insurer %tE;� C CMZ.°M G �PHL tA,E�71 Work Comp#jj;& <br /> TICC Technician's Name Expiration Date <br /> QICC Installers Name '" <br /> R ' /�/kms T�,�p Expiration Date y_l 7- .1611 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> A <br /> N <br /> K <br /> P E- Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name C�' d 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 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 <br /> TO 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 /> Applicant's 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. <br /> NAME C/Z j� '.fj�+1�L'�A/ TITLE �L ' �I�'g�X C rl(� YIONE# '1� �'13 <br /> ADDRESS7;�ZZ� <br /> SIGNA RE-'-QDATE <br /> EH230 8(revis 02/20 <br /> 1 <br />