Laserfiche WebLink
SAN JOAUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,300 FLOOR <br /> STOCKTON.CA 96202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> & TANK RETROFIT_PIPING REPAIR/RETROFIT ,UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> +ii{ --+-_-----_---- --------=—�---------l-1—O`I--{--W-----C-7r—f/—--_�L_�'_"/_� <br /> G—)—----Q------- ------- --'" //---�--Ql�-"__� -yJ�^�-�7 <br /> -.-.�--O--7---------- <br /> + <br /> ----------------------------------------------------------------------- <br /> i PROJECT CONTACT & TELEPHONE # C�K�EPA SITE # ------ <br /> PHONE # xpRW <br /> F1 FACILITY NAME -------.-------------------------- --------------- -------- - ------ <br /> C ,I{ <br /> { ADDRESS WI�o/p LN eF <br /> L CROSS STREET <br /> I +----------------- ---------------------------------------------------------------- -- --- <br /> ---- -------------- - <br /> 1 T 1 OWNER/OPERATOR /01111/ u1w,Q p— , PHONE #2017- <br /> .. <br /> '7®� <br /> i Y ✓ �L f ------------ <br /> � <br /> C ; CONTRACTOR NAME i syn /-�2 G i ,7 lc.t�'(/� PHONE 11 -36�. 7 p O <br /> O +--------------------- ---r ---------------_------------------ -;-ca nic n y �p`-- -cLHs5 p ------ <br /> { N { CONTRACTOR ADDRESS Q,t og+ O!�(C�/ l [ — --------^-- ---------------------------------- <br /> T I <br /> --------------- Ld / <br /> i .F - WORK.COMP.# mac,2 y4 b <br /> ' R I INSURER E _ ----------------; <br /> - --- x ��'�----- • �' ----------------------------+------------- -------- <br /> 1 C 1 OTHER INFORMATION <br /> ------------- --------------------------------+---------'--------------------'----------1 <br /> O ---- 1 PHONE # <br /> R +_______________ <br /> ---------------------------`--- <br /> ' PHONE # <br /> i <br /> 11,1 1,111,:, S ,,,,, , <br /> 'TANK ID # ' TANK SIZE i ICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 1 39— 1 /,a QOC3 t�q � /rC G4SCV <br /> 1 T 39- 6rq I Cw,t0lHP <br /> 1 A { 39— — iQ�......- <br /> N 39— 1 <br /> K ; 39- <br /> 39- <br /> 39- <br /> +--- <br /> 9-39- <br /> 39—+--- iii{ii;{ii„iii{ilii{{{{{{{,, i,{{�1,,,,ii;{{iii{{{i;;{{i;;i;iiii M i;11:1:i;iiia,iii „i, <br /> P { <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> 1 A IS ATTACHMENT WITH CONDITIONS) <br /> N i PLAN REVIEWERS NAME `1IIY1N DATE <br /> i <br /> APPLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CBRTTFIES THE FOLLOWING: "T CERTIFY <br /> t THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> I FOLLOWING: °I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> APPLICANT'S SIGNATURE: TITLE EIeBl�Yp✓4S' to r DArE//—a,7 p6 <br /> — — -------------"_---------------------------`---------+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per flank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br />