Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 IjCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Veronica Freitas 916-373-1167 <br /> A <br /> c Facility Name Fjfven #19976Phone# <br /> I Address <br /> L 1199 N Main Street, Mnnteca, CA 95136 <br /> 1 Cross Street North ate Dr. <br /> T <br /> Y Owner/Operator _Eleven, InPhone# <br /> C Contractor Name Phone# <br /> 0W.Iton EnRineering, Inc. 916-373-1167 <br /> "r Contractor Address P.O. Box 1025 West Sacramento CA CA Lic# 617238 ClassA B Haz <br /> A Insurer Work Comp# <br /> QBE Incurnnce Corp WC4000674 <br /> TICC Technician's Name Expiration Date <br /> ° ICC Installer's Name Expiration Date <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 /> T MSC Cold Start <br /> A <br /> N <br /> K <br /> P ❑ Approved XApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name a / 1 a r'o;40 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 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 /> Applicant's Signature Title_Contractor Date 1110112013 <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 Veronica Freitas TITLE Contractor PHONE# 916-371-1167 <br /> ADDRESS P.O. Box 1025,West Sacramento, CA 95691// <br /> SIGNATURE DATE 11,101.12013 <br /> EH230038(revised 10/30/12) <br /> 2 <br />