Laserfiche WebLink
f i..T.jh.P" m'.�'y Y' f � ♦ a.R"+.�'� "Y'MAtA <br /> • ' T.m sb .s. •.�, r'r m . + }rr ., ..r <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 <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/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# , <br /> A <br /> Facility Name Phone# <br /> I Address <br /> L 4� <br /> TCross Street { r y <br /> Y Owner/Operator O "CA <br /> hone# <br /> C Contractor Name hone# <br /> N Contractor Address <br /> T ClassRInsurerA A ork Comp# <br /> T ICC Technician's Name <br /> Expiration Date <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size ChemicalStored Current) Date UST <br /> Chemicals(i.e.87 piping sump,91 leak detector,UDC 112,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L <br /> A ee Attachment With Conditions) <br /> N Plan Reviewers Na <br /> Date <br /> APPLICANT MUST PERFORM ALL ORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONME TAL 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 FORHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> iZ CALIFORNIA." _ .W <br /> Applicant's Signature Co\ 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. �r� <br /> NAME����E. T( 5/ nC 6`�m1�� ��;� �'�(�}(1 2<R <br /> ` _ <br /> _TITLE— `�`' `f (XC)_PHONE# 2< 0'� <br /> ADDRESS <br /> SIGNATURE {(Yn DATE--Ql t2-0 <br /> EH230038(revised 08/1/11) <br /> 2 <br />