Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SRN JOAQUIN COUNTY <br />1868 E. Hazelton Ave.., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES, 18.0 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />E1 TANK RETROFIT Q PIPING REPAIl71RETROFIT ) UDC REPAIRIRETROFrr 0 COLD STARTIEVR UPGRADE <br />F <br />EPA site # Project Contact & Telephone # -,jt 11? ACd Ay,vn,61 <br />A <br />C <br />Facility Name �f PO vjL &-, -!-J' x%17 ! Phone # qzS- 0 LIZ .11 (j."- <br />.;Address <br />Address%j6, 3 V,46,41e A09 <br />T <br />Cross Street 6V';0 J k t.-7" Q sft <br />Y <br />Owneribperator G: J ,�� ,.J C _ � � (ice � . <br />Phone # 92- -18Y2-1165 <br />0 <br />Contractor Name (0/? Y"og f�L y <br />Phone # 6. <br />N <br />Contractor Address '�!y� tf7 _ CA Lic # 3oG . ClasT <br />R <br />A <br />Insurer y L , z .a <br />Y�/.��'/�� � .�.i.�c, r /� - �-'w � � 71/j,� <br />work Gom p #6,q � y 70 2-7--? <br />T <br />ICC Techniclan's Name <br />Expiration pate <br />R <br />ICC Installer's Name 1)61) f1540Z'14 <br />Expiration Date y ^!Y-16 <br />Tank system work area <br />(Le. 87 Piping sump, 01 teak detector, UDC W. etc.) <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />7 -) <br />is <br />N <br />K <br />cl <br />/G31; 6; /-1 <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(SeAttachment With Conditions) <br />A <br />N <br />% <br />Plan Reviewers Name Date r <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 POLLoWNG: "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 T1fE FOLLOWING: 'I CERTIFY <br />Tt{AT IN THE PERFORMANCE OF THE. WORK FOR WHICH THIS PERMIT IS ISSUED, 1814ALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Appllcanf'sSI nature _ TitlaII��rG�i ��0i"A+2 Dale <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 r6 L!l[��jl'allf�Jv� TIT1(PT� PHONE# " { 9"19 6"16 S <br />EH230038 <br />2 <br />