COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3"0 FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM TH APPROVAL DATE. DO NOT WRITEIN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT + - - - --------- - - EPA'SITE # --------- ----------------------- PROJECT CONTACT &TELEPHONE # s I +---------------------------------------- -- __ _�� y---�°1 -SyV_7- 3� --- ------------------------ F ; FACILITY NAME A + �C.2�3 1 PHONE # C� T! g-SSSZ C I ADDRESS a�_�__elYY�ili1_?StT__!Ll_✓_ S'CO_G_14.,t?I_ I L I CROSS STREET i I ---------------------t_ ��QT TI OWNER/OPERATOR I PHONE N 1 Y �iz4Q---G S -P s I + -- - - ------ - -.................. - -- - - 1 I ' C I CONTRACTOR NAME-.''(Z-C� ��. �� !_ � I --�-� I`-�-1-o--�3QQ---------- 1 0 +----------------- W,END_l_ �i. 4 S y� '-------------------------_----- `�Z_I I_Q---- I N I CONTRACTOR ADDRESS l I CA LIC # I CLASS T +------------------ 3g�_l__��4rtxr.r._•� ? / �} A / R I INSURER —12-33 o- ------------------rC��, #Kj". Y 1�1 WORK.COMP.# C I OTHER INFORMATION I T -------------- 1 i -----'----"-'--'-------'---------------- ----- ' 0 ' 1 PHONE # R+------------------------------------------------------------------------------------+---------- -'--- " --------------------'--i 1 PHONE # 1 1111�111IIIIIIIIIItI�II11111_______________________'___'__'______.____i TANK ID # 1 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 39- 1 39-A 39- 1 1 1 I I N 1 39- K 139- 1 1 1 39- I 1 I i 39- 1 1 IIIIIIIIII 11111111111111 II 111 II 1111 I I 17II I I I I I I I,I I ill I IIIIII: IIIIIII PI 1 L i APPROVED APPROVED WITH CONDITION($) DISAPPROVED A 1 (SEE ATT 'H ENT WITH CONDITIONS) N i PLAN REVIEWERS NAMES - �p n DATE + II111>IIII111111111111111 I r -ilTl Il 1 {Il 111111 l I I I fI1TTTI111t1 Irl III 7-7— APPLICANT I 1 I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF � SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLONING: "I CERTIFY I 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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 , i i I i i APPLICANT'S SIGNATURE: TITLEJjLW3G"W_ DATE -------------------------------------- BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment 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. Name Addressc,?Aj 2 PC114-flbrc-✓(§- Phone # -111( (D7U-S3c�C� L� •PRumP, j c►, g06z3 Signature— Nr- Nr ,<.,,,: Q 0'� EH230038 (revised 1/31/02) 1 .