Laserfiche WebLink
ii/oNbV. 8. 20105: 3: 22PNk 2o946 33 sac EHD 4P No. 3880 P. 11002002 <br /> ENVIRONMENTAL HEALTH <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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PPRM1T TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETR0FIT,9 UDC REPAIR/RETROPIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephon9 <br /> C FacilityName v y a , Phone# 40 4 i j Z/ro,5' <br /> L Address i7,3 g fef <br /> TCross StreetAI <br /> Y Owner/Operator f. v/o m� �, ( f v d�/,� <br /> Phone# <br /> C; Contractor Name �• �i1/d' U Phone# <br /> 0 <br /> 7 Contractor Address CA Uc# :S/,��..�`fes Class�lC;�/0`/b s x <br /> A <br /> Insurer �� '� ri/ j v t c-, Work Comp# <br /> T ICG t'echnician 's Name ,r`eG.4, E_xpiratton Date; <br /> R [CC Installer's Name r.1A r,, /<'r� � Expiration Dale , �� s, Zp <br /> Tank system work area Tank SI2e Chemicals Stored Currently Date UST <br /> (I.e.07 pift sump,e9 Iem deteew,UDC 112,ela)i Installed <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A / r <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK INIX&ORWCE WITH SAN JOAOUVOUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTWENT-OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'i 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 <br /> TO WORICaR'S COMPENSATION LAWS OF CALIFORNUL" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 9 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 /> Ap <br /> Iloanl's Slgnalure Tills g"j a er A Date <br /> BILLING INFORMATION; <br /> indicate the responsible party to be billed for addilional EHb 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 ��rr�t� � <br /> sl acknowledge NS <br /> responsibility for the billing by signature and Oale below- <br /> $,4# Wl"1 <br /> NAME TITLI5 HONE# <br /> 6 <br /> ADDRESS <br /> ..eI Flu i a 41 P <br /> SIGNATURE DATE,'' ' <br /> EH230036 ed 02120109) <br /> 1 <br /> OV 0 9 2010 <br /> EN\,`,ry10 k',. -'NTAL <br /> HEALTH I° PART?o ENT <br />