COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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• • SAN JOAQUIN COUNTY MAR 1 8 2ANVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3fD FLOOR STOCKTON,CA 95202 E!VVit ;in' i!vliL-iQT HEALTH PEt iA I SERVICES APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ---------------- ---------------------------------—_-':------------—----------— ------------- --—+ �---1 EPA SITE # i PROJECT CONTACT & TELEPHONE # �/61411 SCNc'-IrC�Z. r 2W144.; '3jJS L �' llCG) -------------------- F 1 FACILITY NAME AR LV -,IfoI15 3 1 PHONE # ,?o-I A'7t':555�02., 1 A +-------------------- --------------------------- ------------------—-—------—---—----------------—------ "? 10k ,(3E�t1,.=fAr�1/r! �/OLT 7R, _`iZc K>vr[ , -4, 1 C I ADDRESS C -------------------------------------- ---------------- L ----------------------------L 1 CROSS STREET -------------------------------------------------------------------------------------------------------------------------i T 1 OWNER/OPERATOR �/0 ry E51 06A5/ P2�'ouGi"� LLL=' PHONE # Y 1 eG C + CONTRACTOR NAME 7A/i C-AIVIR0,UA16474j- a 45rT-A1S 1 PHONE # N 1 CONTRACTOR ADDRESS 1b'63 rJ•NE✓r LCA `J�•, D�i---b C L'-- 1 CA LIC # 6 - _------ 1 CLASS 4.. - g, C I-- ------------------------------------------------ ------- ------------- - R 1 INSURER B9 iN VKC- Sc U 4,7 W I r Z INS. 0,2C fLC oz i WORK.COMP.# C i.2 6 C'CCI�.S I C 1 OTHER INFORMATION i I --------------------------------i O 1 PHONE # PHONE # 11111111111111111111111111111111_____.._______ _______________________________________________________ +---11IIIIIII1111111 X111111111111111 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED I � 39- 1 T i 39- I I 1 A 39_ 1 N 1 39_ 1 1 K 1 39_ 1 39- 39- + 11111111111111111111111111111111111111111111111111'11111111111111MMM 11111111111111111111111111111111111111111111111111111 p i I L 1 APPROVED APPROVED WITH CONDITION(S) DISAPPROVED 1 A 1 / (SEE ACHMENT WITH CONDITIONS) N 1 PLAN REVIEWERS NAME " 1 � D .( DATE +---I IIIIIIIIIIIII1111111111111111 II '17'1111110'' 111111 1111111111111111111 IIIII 11111111111��l II11111111 1111111 11111 IIIIIIIII111 I1111111111111111111111111111111111111 II111111III II��I11111111111111111111111111111 11111111111111111111111111111 I i I ' APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." I 1 i I i 1 } 1 1 APPLICANT'S SIGNATURE: / W u Ltii ��L12/j TITLE IJ 4h✓ DATE I � � fI --------+ BILLING INFORMATION: D - _ Asafoy � by Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payrrfer� coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NameuC Address Ur;� c� , 1 . �;�s Phone# -z eo Lq 1