Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVEE)Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> FEB 2 5 2m <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL. <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: HFAITN ncp,QRT'jAFAIT <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START,//EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 146q-4h/eeo t�fH561,1 11411 <br /> � Facility Name r('t,.C' r[.t C k 4ti d Aa z1 IPhone# Z��"1 ' - cir✓?�v <br /> � <br /> Address /J, j 61v-d , <br /> TT Cross Street Z � <br /> Owner/Operator Phone# ZZ rj - ?�`Z-,rd CG to <br /> b .e, - u,-4-1� <br /> C Contractor Name Lek7.traI Pc---ft^o /e it ti L- Phone# `l(oZ 404e 0/ <br /> N Contractor Address j'7(p CA Lic# rf j G} � Class <br /> T <br /> R Insurer (YI.r dei 1,LU Work Comp# A O-W 7._&�- / 9- <br /> A <br /> T ICC Technician's Name 1"0 L1Gte 1 Expiration Date D-7 11 l "1 4- <br /> R ICC Installer's Name r e ,,� ����Z Expiration Date � Z lc` &v 17 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Apprc ved Approved with conditions ❑ Disapproved <br /> L (Seek chment With Conditions) <br /> A <br /> N Plan Reviewers Name iW k L Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J IN 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 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I 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 /> Applicant's Signature 4t&I61-. ITitle Cid Date e z, <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 /> NAME J<e4hlee-0 /�ei?S6tJ TITLE L <br /> �L� - -0 PHONE# ��LJ�- �G <br /> ADDRESS I It C�✓V) 1 S� �IE�q S`(y)f-ori CA q <br /> IP /dir <br /> SIGNATURE DATE ©Z A <br /> EH230038(revised 07-17-2014) <br /> 2 <br />