Laserfiche WebLink
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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT. ❑PIPING REPAIR/RETROFIT KUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# _L `b_ -) _1 <br /> � Facility Name ('� �7„ Phone# <br /> L Address is7bs- `i , k UA ot5-3 6 <br /> Cross Street <br /> T W <br /> Y Owner/Operator �V,,.L• Phone# �Sk17 _ (OSI - gS,Zjo <br /> C Contractor Name — Phone# <br /> Q VJ A� v.�er'�r� 'Sx.�. CIWO - 20-6- ►1(06 <br /> T Contractor Address d 1p �,. G S A Lic# (D�'"( 238 ClassAZ <br /> R <br /> A Insurer � � Work Comp# <br /> T ICC Technician's Certification Number Expiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T tok< M <br /> A 2- IL)k 3-) <br /> N <br /> K <br /> P ❑Approved ❑Approved with conditions ❑Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name Date <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: N CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signa a Title Cc9,,, Date r 1.7'0 00 <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 for the billing by signature and date below. \ <br /> NAME Jl�\4:�yis, b� TITLE C°C?v� C PHONE# CW0 \�b� <br /> ADDRESS. •�bx tDo1 S �,J • Cj\ GLS(0�1 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />