Laserfiche WebLink
Dec 291012:58p tictank 3J$532898 p.3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TEAS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> I TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETRORT ❑ COLD STARTIEW UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> Facility Name t {��e, („oLk Phone# 209 -3Z�- G�S� <br /> IAddress 351 �, ktrW r l2oc�d <br /> L <br /> TCross Street E7 F� <br /> Y UwnerlOperator 1 x c,. � -LLo c Phone# <br /> ,.,� l 4W,or <br /> c Contractor Name 00 t�n1� ( r,n i ` s ec�I on Phone# ?j(vO b 1�1 <br /> D <br /> N Contractor Address 0 & ��$�7 'sem i Q b�,j CA LX# $-la (0(0 Class <br /> T <br /> A Insurer Work Comp# <br /> cICC Technician's Name Expiration Date <br /> T <br /> R ICC Installer's Name (Y cf-als KIA&I Ip(oo4b-5- Ll1 Expiration Date i3-28~ It <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping semP,91 leak detach,UDC W,ere) Imstalted <br /> T QS: -* i�0 14MC iel z <br /> A <br /> N <br /> K <br /> p ❑ Approved proved with conditions ❑ Disapproved <br /> L (Sa Attachment With Conditions) <br /> A1 <br /> N Plan Reviewers Name -Date -)_ 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 't CERTIFY <br /> THAT IN THE PERFORMANC OF THE WORK FOR WHICH THUS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> AppticanYs5ignwatwu c Title � r NWf1'�- Date ��� tE} ZOID <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 slgrrature and[tate below. <br /> NAVIEEr� t�C-OTT at s TITLE OWV� N WTLi PHONE# %_0 <br /> ADDRESS ✓L�� Z� 5�" V GLS cpvV�2.r r 't�J to(o{ <br /> SIGNATURE J DATE Ell I I SO 10 <br /> EH230038(rev" U aw4j <br /> i <br />