COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD FLOOR STOCKTON,CA 95202 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 X PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +------------------------------------------------------------------------------ — HPA SITE # C..{}1?QO�M _H,4 a -----PROJECT-CONTACf_R TELEPHONE Z ,and - 1-�J Js ' 1 Cl7�`n, - [ --Sa - - -- �------ ------------------------- p I F I FACILITY NAME - U S f"-_vU�_�s�5 13------------------- ------------------------------------ C �--� �-------Q -8-- _________PHONE_ _�__ _ _ ___ Y__ C ADDRESS L+C� c-- q 5a_1 `� L CROSS STREET �, Le-e L'u Q ,---_------- I ------------------------------1- -----------------------------------------------------------------—---------------------- T OWNER/OPERATOR PHONE # - --- --- ------- ---- --- - -- - +--------- -- ---- -------- C CONTRACTOR NAME � PHONE # I0 ------------------------------f --Y10i--�=------ — G'_t 1_�-------------------------------------- ------`---�—---�,—I--' N ! CONTRACTOR ADDRESS I S i le i mQ5 1 CA LIC # -jg1lags ; CLASS 1 � Z K^ ' _ --------------- �-- ---- --- -- � ---— �sLr�-- -~ T +------------ - y-------------------------------------------------- �- R INSURER,- e n WORK.COMP ,-f-0 = O y -----------.-# S--- -- ----- --------- A ----------------------------------------------------------+ C OTHER INFORMATION --------------------------------- --------------------------------- O : , PHONE # PHONE # +---'• ••II11111111111 {11l �� ,� ---------------------------------------------------------------------------------------------- TANK ID # i TANK SIZE ; CHEMICALSSTARED CtTRRENTLY/PREMQU�SLY DATE UST INSTALLED ; 39- 1 �� In Id-A Q a1 lzd� l�e-r2��C.t�CIIQ T 39- A 39- N 39- K ; 39- 39- 39- + L APPROVEDI I ZAPPROVED I WITH'CONDITION(S)A DISAPPROVEDi 'll A � (S�H`B lATTpv�NT WITH CONDITIONS) N PLAN REVIEWERS NAME fls l.��ITP �� DATE lJ5 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COMM, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY 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 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 ISS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1r� APPLICANT'S SIGNATURE: S TI TLH 'QcSl DATE L'$ W +------------------`---------------- -----------------------------------------------------------------------------------------+ 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 he billig5 by signature and date below. Le,-4V\-h� )�caz g p5 hQmc l-a E�o�� tS�14. NameU W Cas Address/U�wberr��101r� , C4 q)3�Z Phone#(.YO5) 90 4--430 Signature d4 EH230038 (revised 1/31/02)