COMPLIANCE INFO 1997 - 2005 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"0 FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +----------------------- -------------------------------------- - -- ----- ----- -- ------- - -- - ----- --- -----------------+ EPA SITE # I PROJECT CONTACT & TELEPHONE # I +-------------------------- { F I FACILITY NAME $ --------------------�--- ---------i ---------------------------- q�ejo �a�3 < - s2s— ��-- --------------------------------------------------------PHONE # II ADDRESS 1100 5 jil it y1 I/J 57- --L I CROSS STREET ---------------------------------- /N OGfS 7-P_>I4 L -------- ------- ----- - I II +---------------------------------- T I OWNER/OPERATOR y� '• ' '1 �+ /� --------I PH------------------------ ------ - -' Y 1 i3p WEST &) -S7- P/eODue-�----------------1 PHONE j6y9- 3335- ------------------- � ---------- C I CONTRACTOR NAME ---------� -C TR r �� 6 5/5 T� S { PHONE - C (�o I0 ------------------------------------------------------- -- - ---- - -- - - - ------------ ;9----- - -- -- N I CONTRACTOR ADDRESS 3 2 5 3 LLv U Al 6> VR RAS C� I CA LIC # b CLASS 1 I +------------------- C-c> z 1 /� ------ T � -------- -`--/-------- ----�ORl?D_YA_-- --- --- ----- ---------- lf�_ -' R I INSURER ��J�KKE �y^� I WORK.COMP.# ©�fzoco I ' O Z I IAI------------ -------------------------- ----v ------------------------------i- I ------------------------ --- - - C OTHER INFORMATION 1 Oi-----------------------------------------------=----------------------- I R +------------------------ � 7- --- 1��_ �� /TO�/�-----------`_PHONE # 6etjI,J i�t7.7 �1�� ---------------------- ------------i I I FA-y- l!o --- l +---I�I� II�I �IIIIIII �I��II� �II� III -------------------------------------------------�9---- -�5�--------------- TANK ID If I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED 139- 7C i 1&145 I 1 T I 39- I 1 I N 139- e I I � A 39- ,aSn iM65 I i I K 139- ' 139; I 139- I I +---111111 I 1111111 {II{lilllil{{I{1111111111{11111{liililill{li{11{11 III illllllll {illlliiill{Ilill{Ilii{lilliilliillill{Ili i P I L i _ A VID APPROVED WITH CONDITIONS) _ DISAPPROVED i I A I (SEE ATTACHMENT WITH CONDITIONS) Q i I 1,93N I PLAN REVIEWERS NAME DATE +---I{Illllllllllllllllll r Iliilllllllilllilliiil{I Illill{ i {{il{1{iilll{1111 IITI{I { T{{I {II{I{{illl ill li{i{Ilil{i{illillil { 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF � SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY l I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO l BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I 1 APPLICANT'S SIGNATURE: TITLE 1W XfraTE a- 7 6 3 1 I +-------------------------------------------------------------------------------------------------------------------------.--------+ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name ,- l T t�- Vll Sv` Address 32'j",3 LUVW16 off. Phone #916 55-5/-/0 2D Signature EH230038 (revised 1/31/02)