Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> ,TANK RETROFIT ____PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +------------------------------------------------------------------------------------------------------------------------------------ <br /> I I EPA SITE # I PROJECT dbvrACT 6 TELEPHONE # MIC 9 A,&L -W A L►O 1{ N 6 _3 <br /> 1 +----------------------------------------"-------------------- <br /> F ; FACILITY NAME - <br /> ro P '- r Z % I PHONE # I <br /> IA •-------------------- --- -- - - "' - _ -----------------------"-------------""-----------------------------------'I <br /> 1 C 1 ADDRESSd t v a•�Tb"c A S 3 3 6 <br /> I -------------------------------- <br /> L <br /> ---- - - ------ ----W: --- °----5 E---A---E-----� ---- ------- ------ --------- `�--- -- - ------ <br /> 11 `14 I <br /> L I CROSS STREET 1 <br /> 1 It-------------------------------------------------------------------------------------------------------------------"---------I <br /> T ; OWNER/OPERATOR I PHONE # I <br /> Y 1 00(V- S-r O P VA cr2 4 a z-S I S,(A - 6 7+ - $S'0 o <br /> -------------------------------------------------------------------------------------+----------------------------------------1 <br /> C I CONTRACTOR NAME WALT"O �il�G/��!E2r .!�"` - I PHONE # Grj_3�3"-- ------------- <br /> N <br /> rr?.----- <br /> I0 +-------------------- ---------pp--------------------------L---------------------------- J -- - <br /> N I CON'T'RACTOR ADDRESS �• G /�� A �s`4 ( I CA LIC # 6 ('*Z 3 A- I CLASS A 9. 11 A z- <br /> •T �_________________________YX:_^+?.l4S ____-.._-___--.-___________-__-_.___...___-..._____.-___-__----____L--_____---______1 <br /> I R I INSURER STA-YE. f�Unt.�--------------------------------------------- woRK_coMP_# �,/3 - yR 2'� • ------I <br /> 1 A I "-- --- ' - <br /> C ; OTHER INFORMATION <br /> ----------------------------"--""-----------------I <br /> 0 i I PHONE It I <br /> IR ♦----"-----------""------------------------------------------------------------------+-------------------------------------"--I <br /> I I ; PHONE # I <br /> +---11111111111111111111111111111111------------------------------------------------------------------------i---------- ----------I <br /> TANK ID # ; TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED i <br /> 1 139- O1 ; l2. Aoo 1 C, A5aGIAr- 8 1 a LL(L 1 <br /> T ; 39- O Z 1 ( 2. 000 1 r%, AS isLC - I 1 ; UKk <br /> A i 39- <br /> N i 39" 1 1 <br /> 1 K 1 39- <br /> 39- <br /> 39- <br /> 11 1111111 1H 11111111111111111111111111111111111111111111111111111111111111111111111111 <br /> 9_39-39-1111111I1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> IPI I <br /> ; L I _APPROVED X APPROVED WITH CONDITION( DISAPPROVED 1 <br /> A 1 rACHMENT WITH CONDITIONS) 21 e <br /> N ; PLAN REVIEWERS 'm i DATE <br /> IIIIIIIIIIIIIIIIIII 1111111 1IIIIII111IIIIII1111111111111111111111111111111111111111111111111111111111 111111111111111111111111 <br /> I <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br /> SAN JOA=N COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT- OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY ; THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EKPLAY ANY PERSON IN SUCH A MANNER AS TO 1 <br /> BECOME SUBJECT To WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONT'RACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHAD, EMPLOY PERSONS SUBJECT TO i WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.' 1 <br /> I I <br /> 1 I <br /> I I <br /> 1 APPLICANT'S SIGNATURE: TITLE �Il B,s! +4iT DATE <br /> ylt reel ---�A G. !1 <br /> BILLING INFORMATION: tr 4k4 '-- 1e-+--- <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> P.C . Be)( /02S' 94 <br /> Name&C O Ar&L V A���t—Address U). <br /> 1 <br />