Laserfiche WebLink
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 />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # ' <br />1104( <br />G <br />Facility Name PA4 I'Ptjne <br /># ' <br />1 <br />L <br />Address <br />I <br />Cross Street NNI <br />T <br />Y <br />Owner/Operator P Phone # <br />C <br />O <br />Contractor Name ; Phone # : ���j 'i LLt LJ <br />N <br />T <br />Contractor Address Q Q <br />CA Lic # ' Class <br />A <br />Insurer At I i'e-d- I Work Comp # <br />e <br />T <br />IGC Technician's Name Expiration pate <br />Q <br />R <br />ICC Installer's Name <br />0 Expiration pate <br />Tank system work area Tank Size Chemicals Stored Current) <br />0i 6. 67 piping sump, 91 leak deleolor. UDC 112, elal y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions 3.� Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />(,� <br />Plan Reviewers Name ' Q� l- (4 M <br />-- Date <br />.APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQVIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTHDEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FQLLOWWG: "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: "I CERTIFY <br />THAT IN THE PERFORMANC OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPL Y PERSONS SUBJECT TO WQRKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signator Ti6e_ <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 />responsibI for the billing Tb�ydpsigns re and date below. ^'� (� <br />NAME ! l,C�r TITLE PHONE # 1 C� I ",J3 L! <br />ADDRESS Y CJ' JrU 1G�I�1 I '�► ICC. iE(l/L�t t// <br />SIGNATURE lJ8 Lam" <br />EH230038 (revised 02/20/09) <br />1 <br />Cto <br />