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 REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT ❑COLD START(EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# �� <br /> A <br /> O Facility Name p'l6 T Phone# <br /> I Address W <br /> I Cross Street <br /> T -�—� _-�----I <br /> Y Owner/Operator L,4 Phone# <br /> C Contractor Name L_�- 5CC,_)`C_C Phone#(SYI)YYN-( 7 v <br /> N Contractor Address CA Lic# 7 74 Z�� Class ,{ <br /> T N. L�,' .J <br /> R Insurer Work Comp# <br /> A <br /> T ICC Technician's Name 1�J�Cw•� L7w�t � T Expiration Date <br /> QICC Installer's Name Expiration Date <br /> R <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 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 1�:)Ct'to �l at � 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 RK FOP. HIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 11 <br /> Applicant's S gnature ` Title_ 'CM4L 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. c <br /> NAME—t—C- SEC-u t�� TITLE (-o"J« C_Va V- PHONE# 1`� / yy" i73 s) <br /> ADDRESS g L� 1 (1 F' SIJ C7 A �I ��r <br /> SIGNATW_6E DATE 7 q <br /> ` <br /> EH230038(revised 04/30/13) <br /> 2 <br />