Laserfiche WebLink
E <br />09/26/2008 FRI 16:47 FAX 2094683433 SJC BAD <br />2002/007 <br />ENVIRONMENTAL L <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stocictoii, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAift PERMIT <br />THIS PERMIT EXPIRES 980 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />UTANK RETROFIT UPIPING REPAIRIRETROFIT I IUDC REPAIR/RETROFIT / :(H n STARTIFVP I IPf:PAtW <br />F <br />Aid <br />EPA Site # <br />Project Contact & Telephone # <br />0 <br />Facility Name Phone # �— <br />5� 22 <br />Address -) S <br />I <br />Cross Street <br />Y <br />Owner/Operator. <br />Phone # <br />QContractor <br />Name <br />Phone # <br />N <br />T <br />Contra5r Addres <br />Class <br />A <br />Insurer <br />Work Comp #,� <br />o <br />T <br />ICC Technicians Certification Number <br />' <br />Expiration Date <br />Q <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank 10 # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A1® <br />OL <br />�/QQQ <br />N <br />K <br />P <br />UApproved pproved with conditions 1,_.1Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />I <br />Plan Reviewers Name ' ov1/�jn ,22;r1FL.C1441 -'8-1 /V a' Date t $ / (G% 0 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTNIgMIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFOR E OF TTERK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S OMPENSATION 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 />OFCALIFO A" 1(/��y/�y/� <br />j Q <br />Applicants Title Date ` � (J�1l,,Il...� <br />BILLING INFORMATION: <br />Indicate the response party to be billed for additional EFID 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 th billing by signature and date below. C , ` /� G� �j <br />NAME lA TITLE (� 'PHONE >l� 0 G��4 ( (L" — <br />ADDRESS ht ' (1 I��g ) a ' t�'i n� fi <br />SIGNA <br />EH230038 (revised <br />1 <br />