Laserfiche WebLink
09/26/2008 FRI 16,47 FAX 2094683433 SJC SED <br />0002/007 <br />ENVIRONMENTAL HEALTH ®EPARTME �r <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />P <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIA'PERMIT <br />1j THIS PERMIT EXPI EXPIRES '180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW; <br />UTANK RETROFIT UPIPING REPAIRIRETROFIT IUDC REPAIRIRFTROFIT %V[:OI_D START/FVR I IPrPAnP <br />FEPA <br />Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name <br />Phone # io SS 22 <br />L <br />Address 3�-i S <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />0 <br />Contractor Name <br />Phone # - O <br />NContra <br />T <br />r Addres ' w <br />CA l is # ,S Class <br />A <br />Insurer <br />Work Comp #-A <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored Date UST Installed <br />Currently/Previously <br />T <br />QOc3 <br />IN <br />N <br />K <br />P <br />UApproved 546'p`roved with conditions (_-]Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name /iitY1Jl C/{/ f�G"��"t Datel <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, IRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORE OF THEIWORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKERSICOMIRENSATION L LIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN T P RMANCE TH W K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFO A." (� �/�� <br />Q <br />Applicants Tille Dale (.yOy <br />BILLING INFORMATION: <br />Indicate the response 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 thbilling by signature and date below. - <br />NAME TITLE PHONE 1G10 SS2,44�2� <br />ADDRESS 1 "XJ ��IY� J I fl� A <br />SIGNA <br />EH230038 (revised 12131 <br />1 <br />