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# C qProject Contact&Telephone# <br /> � Facility Name &ZVPhone# Q N <br /> � Address -Ft <br /> TCross Street <br /> Y Owner/Operator , Phone# <br /> CContractor Name — ; Phone <br /> TContractor Address CA Lic# + Class <br /> A Insurer ^ Work Comp#L+PL <br /> TICC Technician's Name Expiration Date <br /> RICC Installer's Name 2 Expiration Date / <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump.91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L ( Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date�Z��� <br /> APPLICANT MUST PERFORM ALL RK 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 WORKRR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. p�/7 <br /> Applicant's -Ignature Title e / Q/ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to`b 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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />