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 DALE. INDICATE PERMIT TYPE BELOW: <br /> 71 <br /> )(TANK RETROFIT OPIPING REPAIR/RETROFIT _-UDC REPAIR/RETROFIT _ICOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# r•�0. f <br /> A _foo3 <br /> D Facility Name C.�A-e t•Y'Q Phone <br /> IAddress <br /> 3 _P1_-C-i4t C, !tut 'SAo(j� Q S"1c7 <br /> I. Cross Street <br /> T <br /> Y Owner/Operator ` �voo_ u sA, Phone# ,(q`'i_4,`i`i <br /> C Contractor Name <br /> N �_v\)�( 2.SftA�CC,!✓1 5 She clJtS ��. Phone# `to <br /> R Contractor Address © Q1?� C S �• �� CALic# qj,�-(� Class (p j 46RA2, <br /> A Insurer C w,C�S 'r�5 U fti�1L� �o iLl, Work Comp# <br /> T ICC Technician's Certification Number <br /> O S S'] - 1� Expiration Date <br /> R ICC Installer's Certification Number <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P DApproved Approved with conditions ❑Disapproved <br /> L See Attachment With Conditions) <br /> A <br /> N <br /> D <br /> Plan Reviewers Name <br /> 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 AGENT'S 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 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED,'I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Y � � ��le 1..4 L Date It dwg <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. /D <br /> NAME_rUIR`r LW V-W4EMkt(Nj —TITLE�A� , '1 C-(, NG&CePHONE# 4416­ �U­8- I G t <br /> ADDRESS (o b O_Cpi Ltl. ko-f yet 1 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />