Laserfiche WebLink
RECEIVEL), <br /> ENVIRONMENTAL HEALTH DEPARTMENT7 2014 <br /> SAN JOAQUIN COUNTY ENVIRONMENT <br /> AL <br /> 600 East Main Street, Stockton, California 95202 HEILTH DEPARTMENT <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT IXPIRES 183 DAYS FROM THE APPROVAL DATE. INDICATE PER MI[T TYPE BELOW: <br /> o TANK RETROFIT ,WIPING PFPAIR'RETROFIT t]UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone <br /> A <br /> C Facility Name �uy� py1 0��,�:Y Phone# q-��j-q-71 <br /> L Address �`�O� �- . 0�e.i� 11'E' - C.Ph <br /> I Cross Street <br /> T r1 p <br /> Y Owner/Operator �,��.� u l�CL r Phone# 0�'GOy �iJ <br /> - o 3l'i^ y <br /> C Contractor Name E�`l IS L Phone# - 0 J— S S,& <br /> IN T Contractor Address �i ( e �� e CA Lic# �� 3'7d�/p Class <br /> R <br /> Insurer a Work Comp# 695- .Se-�O/z <br /> T ICC Technician's Name0.�kr-zExpiration DateCL-n ')L 2U—/5 <br /> R ICC Installer's Name j 1 usa vi cl,r,a Expiration Date or?— y <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (ie.87 pioing sump,9'leak detector,UDC Irl,eta) Installed <br /> T : n <br /> A <br /> N <br /> K <br /> P 0 Approved Approved with conditions _ Disapproved <br /> L See '1 N,� <br /> Attachment With Conditions) <br /> N Plan Reviewers Name gee a, wDate `� _ . �r4 <br /> r. <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAVJS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PER=CRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SLCH A MANNER AS TO BECOME SUBJECT TO <br /> 'S <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTORHIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR IA'HIC-1 THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUEJECT TO WOP.KEWS COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> AepHnYs Signature - e•• -" ""f11ey IrfA Date `1 <br /> w <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 fur the billing by signature and date below. /- <br /> NAME A Vi f3f. .5 / Q E' <br /> J%E t � ltrA C fO Ir PHONE# 0 �/ �`0 (li O`7 3 40-3 <br /> ADDRESSI 7� ��[)I� 7y s- ' ,)'l �4LI • 1.� (J� C� cA 2�2L2�/ <br /> SIGNATURE - DATE O a T <br /> EH230038(revised 0811/11) <br /> 2 <br /> t,'d C9689t,960Z Lunepled elge1le2j 86t,:90 V1,LZ ABA <br />