Laserfiche WebLink
01-11-'13 11:54 FROM-West Star Envmt Inc. +559-277-0106 T-880 P0002/0005 F-417 <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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETFIOW 0 PIPING REPAIRIRETROFIT [I UDC REPAIRIRETROFIT o COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility NamePhone# tA tp <br /> I Address <br /> L 1 5_1 E. Nasmt< ocN ca q 15;Yao <br /> T Gross Street <br /> Y Owner/Operator Phone it 0-0)6WB--ks�At' <br /> 0 <br /> Contractor Name raPhone#(155q <br /> r— dim'v% <br /> N <br /> T Contractor Address <br /> ulc CA # 051 tA, Class <br /> Ac# _L <br /> A insurer "r WClWork Camp#C-%,>C 216 'R. eC�) <br /> ICC Technician's Name - Expiration Date <br /> T !a_g r�j kci I ao 12) <br /> ICC Installers Name Expiration Date <br /> Tent,system work area Date UST <br /> Q.&87 ftip%q SU",91 hM dfitedM.L1130 112,ate.? Installed <br /> Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved 13Approved With conditions 11 Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name IV t IVA-(fn'\' Date_I/ 14 <br /> PLICANT 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING; *1 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> kPoicant"s Signature Tide $le <br /> BILLING INFORMATION: <br /> Inchoate the responsible party to be billed for additional EHO staff time expended beyond permit payment coverage per tank. If <br /> the party designated below Is different than the permit applicant, e.g. prop" owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME —TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230=(revised 0811/11) <br /> 2 <br />