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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT KPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />D <br />Facility Name - C L V kirl1P19 9 6 <br />Phone # Z p cI _ Z 39 <br />Address 1 15 q rl , OA A -t N S �— . A\ A-�Vic A C P. g 3 3 16 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator _ E C 0 -VU -4 <br />Phone # <br />o <br />Contractor Name A -CF-1fZ J,— cc _ <br />Phone # 9(b . 3 3 — ((S-1- <br />N <br />T <br />Contractor Address g p / 0 2 (,t j, S P-c�t o c, A 5 j-6 4 <br />CA Lic # ( A, i3 , �4 q <br />} Z 3 >< Class i <br />AInsurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Certification Number S E t A--7- T --A- W" <br />Expiration Date <br />Q <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />[]Approved I�Approved ❑Disapproved <br />P <br />with conditions <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />I _ / <br />Plan Reviewers Name l�/ i L4 L� % Lam- /`I'/ a--- -`& 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 LA SOF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE O THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title Date (L 0 <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 />responsibilit for the billing by signature and date below. <br />NAME l Clh N-� 1 N t�" L 18"� TITLE PHONE # Cl( <br />ADDRESS f-' 0` ✓ 0 (� z i W. A l iJ ( l <br />SIGNA <br />EH230038 (revised <br />1 <br />