Laserfiche WebLink
11/20/2007 08:49 <br />916-373-1172 <br />WANTON ENGINEERING <br />to <br />Ear"I'VOIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Strcet, Stockton, California 95202 <br />Telephone: (209) 468-3420 Faze: (209) 468-3433 <br />PAGE 02 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW.. <br />nTAmK RETROFIT OPIPING REPAIRIPETROFIT lLI UDC REPAIRIRETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # (C H Arles (,(/pi <br />G <br />Facility Name l0 G we P 1 <br />Phone # <br />Address ', o e4 Gi l D,- iF.t2. L o® 2 T o G (L S- Z <br />Cross street <br />Y <br />Owner/Operator t L %x.L b- (0 ( L C d wa p mky t L L 'G <br />Phone # 710- $ k f- - O y® f <br />c <br />Contractor Name 5*e G ( A4 "-it o'-6 +Q C <br />Phone # d7[6 --SJ-3- t (S.2-- <br />N <br />T <br />Contractor Address Cg o , [ t o Z r W - CA -vi -o It $74 `t c CA Lic # (o Class -A, C1 , 6( 42— <br />A <br />Insurer 5T h-� tip i; u t Work Comp # <br />T <br />JCC Technician's Certification Number SIV— A -1-•T' *t -m- -t Expiration Date <br />o <br />R <br />ICC Installer's Certification Number °` " Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />A <br />Q Z'" <br />/0 40 0 <br />® �' <br />rt <br />N <br />K <br />` <br />P <br />Approved pproved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Q Date 111filIj <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING, "I CERTIFY THAT tN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAVV7 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; '1 CERTIFY <br />THAT IN THE PERFO OF E WO K FOR ICM TMIS PERMIT I$ ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />a� <br />Ao[1EloantsSlpnatura TRl� fin° �'"t.7t"®"' DatC_.___ `� I <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 />NAML,:[- <br />TITLE ( 0" PHONE if.`6._`L-- <br />aDnlaEss '. m , ®� o z, r_- _-- W- S A-yt�v C 9 S-6 R 4 <br />SIGNA <br />EH230038 (re0sed 8/3107) <br />T <br />