Laserfiche WebLink
ENVIRONMENTAL HEALTH D• ARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />[6 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />[6TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RFTRnFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # $A C q A tt, LVA c <br />T_ -"A CjIb 3 3 _ W <br />C <br />Facility Name Q v %V STQ a l z s- <br />Phone # <br />� <br />Address / 5. Uj.IM A t ST- 2 c Po h( 5 3 6 6 <br />TCross <br />Street <br />Y <br />Owner/Operator (IL St -'Q P l/b( A-fL 6T'15 �. <br />hone # ro 6 r3 - 8ro 0 <br />TPhone# <br />C <br />Contractor Name {� C TA ,,� " � r< < ►�( �✓�R-tom 4 �c C _ <br />N <br />T <br />Contractor Address o X / o z s- W. S A-c,-t_fl qr4rt t <br />CA Lic # (c ;- 2. 3 r class q 6:. N a z <br />A <br />Insurer ST ck. � 1.':0 �-XD <br />Work Comp # <br />C <br />T <br />ICC Technician's Certification Number S It -A- T <br />HT- <br />Expiration Date <br />o <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />( <br />/0,000 <br />rs <br />A <br />N <br />O t <br />10,00 a° <br />( C. a -S <br />K <br />p <br />rco <br />L El S <br />P <br />❑Approved lq pproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />�l'7/2,/07 <br />Plan Reviewers Name a/t-,(v Date <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: "1 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 HE WORK FOR W CH THIS PERMIT IS ISSUED, I SHALL EMPLOY <br />PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." f <br />Applicants Signature Title C . 4 �'s'� IZ—O h-- 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. <br />NAME U/ 4, LTO s& 1 tk C%. ( #.( V:EAZ-t A( (I TITLE CO *AT IZ- A-V P-,. PHONE #—'7(6 ` 3 } 3 ` l ( J' 2.— <br />EH230038 (revised 8/8/06) <br />1 <br />