COMPLIANCE INFO_2001-2009 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------- --------------------- ------------ ------------------ EPA SITE # i __________ _______________+ PROTECT CONTACT & TELEPHONE # +__________________ _______________ _ 1 _______________________________ (� ____ -i F I FACILITY NAME �--SIiC�.� PHONE # 16 4 S C 1 ADDRESS -------------------- --------------- ---- ---- ---- ---------- i I +-------------- SS ��-Q2 ------- ----- ___________________ L 1 CROSS STREET _______--- i I +__________________________ __________________________________________ ______________________ - - T I OWNER/OPERATOR --- ----------'----_-----i --- j PHONE # i C� ------------ C CONTRACTOR NAME ,yL , I PHONE # ------------------ N CONTRACTOR ADDRESS I CA LIC # CLASS ----------- R I INSURER WORK.COMP.# A --- I C OTHER INFORMATION T+____________________________________ O 1 PHONE # i I PHONE # --M! h HIM! iii IIH i M! iii m 11 ----- ---� TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- i A i 39- N 9 N I 39- K i 39- 39- 39- --M! H HIM 9-39- iiiiiiiiiii M! III! !III! I i M ii ilii h ili!1111 111111ii ii ii iii iiiiiM iiiii h M iii iii i iii 1111MM ii iiiH H H ii P L APPROVED _ APPROVED WITH ITrrION ) DISAPPROVED A I (SEEfA7ENT ITH N6IT 5) i N i PLAN REVIEWERS NAME� iliiiiiiiiiiiiliiiliiiiiii ilii Mii 1iiiii ii1"r-H ii ilii i iHim iiiiil i i APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J i � OAQUZN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF i i SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY i I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, Z SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO i BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO COMPENSATION LAWS OF CALIFORNIA." i APPLICANT'S SIGNATURE: TITLEAAdQ?-DATE -7' a `-v Y, + ___________________________________________________________ BILLING INFORMATION: THAT IN THE WORKER'S Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Phone #