Laserfiche WebLink
ENVIRONMENTAL HEALTH <br /> g = 1 1_—__ <br /> 600 East Main Street,Stockton,California 95202 <br /> isle ira► e® rGOj �,� `� ���fi � ' ,� _�. <br /> n RETROFIT OR PIPINGi IT <br /> F1 TANK RET OF-IT =_, PIPING REPAIR<RETR FI r "D UDC REP AIRFRE I iROFI T <br /> F EPA Site <br /> A <br /> C Facility Name — i Phone <br /> LAddress L <br /> 1 Cross Street 1f <br /> T <br /> Y Owner/Operator 1,4Phone# <br /> 0 <br /> 0 Contractor Name Phone <br /> T Contractor Address1 CA Lic Class, 0. . <br /> A Insurer�v Work Comp# <br /> T ICC Technician's Nameram- Expiration Date <br /> O <br /> R ICC Installer's Name Expiration Date Z <br /> Tank system work area Tank Size Chemicals Stared Current) Date UST <br /> (i.®.e7 P mo.Et ^UDC V2. .' y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ ApprovedAX <br /> Approved with conditions ElDisapproved <br /> L <br /> A ee Attachment With Conditions) <br /> N Plan Reviewers Name Date 9 o I <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY THAT IN <br /> a 1 iE 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 /> ,Wt <br /> eO' RKF ^fi r� �,`ION i Aft,-,OF C`�a,.fl=a`RNjA t Oi�aTRACTC0r S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING! "I CERTIFY 1 <br /> F TI�n,T,d , t 0R ddf.1.H TI iS Pt»RPAI T 1S IS,3UEi), 11A:IL IT TA ,,_:Y , .S;. <br /> � .v,:,J;tiidi.EOr ,}..L_vJGP ..., .,-.,_ ........ .. .«...,_ .. . ._ <br /> VP IiMLIP VECIV1A." <br /> 1 <br /> Applicant's Sag )Pre Title afe <br /> BILUNG NG INIGORNI®TION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond pe it pavment coverage per tank, If <br /> th_ narty d ianrtn; rr.r:;jot Ig difforpnt than the nerrmit 2nLNIi-nnf ot7 nrnnP,*v ntA -r thA �nqr -mina n �.nns',jr!a *1'`:`,^ <br /> re pons'Ibilit//or the <br /> bibilling <br /> �by signature and date below, V <br /> NAItiIE < ._._��77tb��—�� 1✓ 11�1 }�TITLE_ �-_ �j <br /> �,�,�.. �l1— _PHONE# <br /> A'u"JI?EvS1j,7'� <br /> DAT C <br /> or <br /> EH230038 ised 02,20/001, 7 <br /> i <br />