COMPLIANCE INFO_1999-2003 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R°FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT X8 ____ leftf:REPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------- --- -------------+ 1 1 EPA SITE # = PROJECT CONTACT & TELEPHONE # I +------------- - --------------------------------------------------------- - - - - - - 1 F I FACILITY NAMEI PHONE # / _ A +--------------- -/-/�.1 /��/J/�JJ��'/� 1 i + ADDRESS------/ l!/-[__- --fes-/' WOW- --C_�----------------------------------------------------------------' L 1 CROSS STREET 1 Z +__________________________________ ___________ ___________________ ____________________________________1 -!/' nn ------------------- 1 T 1 OWNER/OPERATOR 1 /�V I PHONE # 1 P0 ISOX -+---------------- ----------- - - +- I C I CONTRACTOR NAME I PHONE k 1 1 N I CONTRACTOR ADDRESS I CA LIC # 1 CLASS - 1 1 -------------------------------`-------`----------------------------------------------------1 1 R 1 INSURER 1 WORK.COMP.# 1 ------------------------------------------------------------------------------- 1 C 1 OTHER INFORMATION I IT +____________________________________________________________________________________+________________________________________1 0 1 1 PHONE # 1 R +____________________________________________________________________________________+________________________________________I 1 PHONE # I +___11111111111111111111111111111111______________________________________________________________________________________________1 TANK ID # 1 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE US INSTALLED 1 I 1 I 139- I � I T 1 39- I A 1 39- N i 39- K 39- 39- 39- +---:I HIH!IIM!1!111 HIM!lllli�li MIMI iiii M 9- 39-39- +---11111111111111111111111111111111111111111111111 111111'I11111111111111111Ill 111111111111111111111111111111111111111111111111 P 1 L 1 APPROVED PPR. WITH CONDITION(M/ DISAPPROVED I 1 A 1 E ( ATTA WITH CONDITIONS) 1 1 N 1 PLAN REVIEWER NAME DATE I + iiiiiiiiiiiiiiiiiiiiiI T-I T1-1IIII iiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiii 1:111111111 111 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 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 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1 APPLICANT'S SIGNATURE: TITLE0(lafl fYaW�DATE i I +----------------------------------------------------------------------------------------------------------------------- BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name---------------------Address— ----------------------Phone #----------- ,�/— se�_ ,-'e "4 .