Laserfiche WebLink
ENVIRO• ENTAL HEALTH D • RTMENT <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 />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELONG <br />UTANK RETROFIT UPIPING REPAIR/RETROFIT ( h Irv_ P aA <br />F <br />A <br />I EPA Site # <br />Pleject Contact & Telephone # <br />C <br />Facility Name <br />Phone # <br />1 <br />L <br />Address <br />- <br />1 <br />Cross Street <br />T <br />yOwner/Operator <br />Phone # l �© <br />c <br />O <br />Contractor Name l , <br />i <br />Phone # '�t _ <br />TContractor <br />Address <br />CA lic # <br />Class jq <br />R <br />A <br />insurer <br />Work # W <br />Comp �vo <br />C <br />T <br />ICC Technician' Certification Number <br />Expiration Date 1 <br />R <br />ICC lnstaliel's Certification Number <br />Expiration Data <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Dale UST Installed <br />T <br />A <br />N <br />K <br />P <br />L]ApPmved <br />&pm ed with <br />conditions <br />L1Disappmved <br />L <br />(See Attachment With <br />Conditions) <br />A <br />N <br />Plan Reviewers Name / (/ <br />Dam -T--r <br />APPLICANT MUST CORM ALL Y4CM LKA A{C.1lSRfTK-$AN Jg444NC4JN IY.OR9iMAN ..STATE IAY�S _ AMU RUE -5 AND -REGlAA7XXIS OF SAN <br />JOAOtAN COUNTY, ENVIRONMENTAL HEALTH OEPARTMEt+ T OMJER OR LICMSED AGENM SIGNATURE C Sn IFIES THE FOLLOVAC: "1 CERTIFY THAT MI <br />THE PSiFORMANCE OF THE WOW FOR V ICH THIS PERMIT IS IS%JED I SHALL NOT EMPLOY ANY PERSON IN SLAOI-r A MANNER ASTO BECOME SALIECT TO <br />V140RKERS COMPENSATION LAWS OF CALIFCI*U CONTRACTORS FIRING OR SIGNATURE CERTIFIES THE POLLONIM 9 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR VNiICH THIS PERMIT Is ISSLED, 1 S -TALL EMPLOY PERSONS SUBJECT TO MWZR'S COMPUMTION LAWS <br />OF CALIFORNIA" <br />Cwt -t C)i <br />INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff Lane expended beyond permit payment coverage per tank- tf <br />the party designated below is different than the permit applicant, e.g. property owner, the .party must acl mowledge this <br />respo sibility7forth bitfing by gnature and date below.,�y �NAME t �/1 1. Y�c�, TITLE 6S ` A . PHONE # <br />EH23DO38 (revised 81806) <br />Ir • <br />