Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START R UPGRADE <br /> A <br /> F EPA Site# Project Contact&Telephone# <br /> `/�//- <br /> G Facility Name L)Y, i e 7T�P Phone <br /> I Address v DLV74-r ow b C w D <br /> T <br /> Cross Street <br /> Y Owner/Operator C!C 1,11—Tc— Phone# <br /> 0 Contractor Name Phone# 7d7—q37"v6,r <br /> o rrnL� ovr' �c, 9�ev,rYt �Ir✓�c� ct <br /> T Contractor Address,244Lj <br /> 0 eG �i 6+�{f A Lic# � 7 ( Class n <br /> R Insurer n X32 C�10 <br /> A 6+A_'C rY1 Work Comp# �D73g y <br /> c ICC Technician's Name <br /> T ((;x vy Expiration Date a—(o—I Cl <br /> R ICC Installer's Name „((11 —)P—��y <br /> Pa�-,rr c k f'r e� Expiration Date <br /> Tank system work area Currently Date UST <br /> nk Siz Chemicals Stored C <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with con ons ❑ Disapproved <br /> L (See Attachme <br /> A nt With Conditi s) <br /> N Plan Reviewers Name <br /> D e <br /> APPLICANT MUST PERFORM ALL WOR N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STAT LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL ALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE C TIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK F R WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN CH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATUR CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OFT E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJ T TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Date <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 /> NAMEo�L]''i1Cj �'f'!1'1 �' TITLE �Y- G° PHONE# � �J� <br /> ADDRESS 1 C_IX 7Va Cn y ) ( l <br /> SIGNATURE DATE v_1 I — <br /> EH230038(revised 12-11-15) <br /> 2 b — 11 <br />