Laserfiche WebLink
• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />Ld <br />TANK RETROFIT ❑PIPING REPAIRJRETROFIT UDC REPAIRIRETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # / r` t 01R A. p,L WA 0 4,,1 4 3 _ 1 t T <br />APhone <br />C <br />Facility Name Q U l le- S t- 0 p / i <br /># <br />� <br />Address 0 V 4r1 &S S Z- _ q C A S' 3 3 6 <br />TCross <br />Street <br />Y <br />Owner/Operator 0 v UG S T"O P ply kR e &i1M <br />Phone # S t o- 6 T-)- KS -00 <br />c <br />0 <br />Contractor Name ,A, (,� F-4 �\ t I4,Lri1� 6 A4C � _ <br />Phone # <br />N <br />T <br />Contractor Address .�• 0 2 f Aim 4t <br />CA Lic # , �, 3 Class $ W Z <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number S A -r-7- A..{ w" <br />Expiration Date <br />R <br />ICC Installer's Certification Number S S lz Ae-'l--' Ac#At <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />N <br />K <br />o 3, <br />DApproved Approved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name VVWA/ �1 %�(/t iL� � Date ��� j 0 <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 HE WORK FORWHIC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature"-IN&k:� Title 02 +— ate- Date It 6 O o } <br />BILLING INFOKMHI ION: <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. /1 <br />NAME V ISI % C LA 4A, -L.. OA TITLE N O—T—iZ A4," -x PHONE # 9!6 - 3 3- 3 —1 If L— <br />ADDRESS �� Q` 6 0 X 10 T U- S A4,ty C A <br />SIGNA <br />EH230038 (revised <br />1 <br />