Laserfiche WebLink
t M <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> XTA RETROFIT ,}LPI7PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 2A)I— 5 — 7 d <br /> � Facility Name A�2YWi0- A s Phone# aq-9S — <br /> I <br /> L Address i 2X w. A4 M M� uA VIS TO C 4--W. CA0 <br /> TCross Street <br /> Y Owner/Operator gj/ yttvj bIL (0 Phone# V q-4 8-a—x11,10 <br /> oContractor Name Phone# <br /> N Contractor Address CA Lic# Class <br /> T <br /> R Insurer Work Comp# <br /> A <br /> T ICC Technician's Certification Number Expiration Date <br /> T <br /> R <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 14)t n L U h � <br /> A 7 $ boo Pfi.yr,�VYA uy tlq t <br /> K <br /> i <br /> P ❑Approved ❑Approve with conditions ❑Disapproved <br /> L (See Attachm t ith Conditions) <br /> A 15-1 <br /> N Plan Reviewers Name — Date <br /> 0 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTYD ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGEIYZ'S IGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY A Y PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRA ING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN OF THE WORK FO ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY ERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title V't Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party tb be billed for additional EHD staff time expended beyond per it payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, th party must acknowledge this <br /> responsibility for the billing by signature and date below. pJ p <br /> NAME AMRxiPA L 1 tw iort rA TITLE 2��lWLJL PHONE� q . <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />