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 /> TANK RETROFIT L_PIPING REPAIR/RETROFIT __'UDC REPAIR/RETROFIT DCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Ra vI e cf Vl,&& <br /> vi 8-�)c3 (O� <br /> A <br /> O Facility Name �'Irl-E u1(L�t S� Phone# -,)()q_ i...f q q_4a94 <br /> � Address (Q 33 T 5 CIL (I G3�p7 <br /> I. . Cross Street <br /> T <br /> Y Owner/Operator CIvkjA ntA USA Phone# aQQ_4'17- Lip 94 <br /> C Contractor Name <br /> o cc•E.Sfxiwi+ S 4: ituC 1wc- Phone# .EOQ I3- (c03S' <br /> N Contractor Address , 0 Qu CLk(,l IILUC., CA Lic#qTi O gy Class a,e_&M%G K+ <br /> R Insurer <br /> A C c5s Work Comp# 0(43(off$ <br /> TICC Technician's Certification Number 6 <br /> Expiration Date <br /> o <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved %Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A ^� <br /> NA <br /> Plan Reviewers Name �,�;`� �� 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." o- G <br /> Applicants Signature f un'4. LL ti VTitle C6&bj .e r Date 1 cam}i <br /> BILLING IN ORMATION: <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 they ' <br /> billing 1by,signature and date below. <br /> NAME()(►�I L1�Lt W -11i4kWLL Vi TITLEQID ft (,(},(� -C 64IGer PHONE#40� <br /> ADDRESS k O QVii-kvtt JCI Lk SOSOL A3-- <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />