Laserfiche WebLink
• • c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER-AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM W: <br /> M THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> _TANK RETROFIT✓OMPIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> --------------------------------------------- -------------------------------------------------------------------------------------+ <br /> ' I EPA SITE # -. -:'PROJECT CONTACT & TELEPHONE # tQ. �G .. �/•YT��-_4a\Cs�C�'�1� �� <br /> +------- -- -----------/-,-,-T-- - ------------------------ ILV9�1�x1 <br /> F f FACILITY NAME ----------------------- -PHONE-#_ <br /> fA +------------------ <br /> C <br /> I ADDRESS <br /> I ------------------ � n— -------------- <br /> L 'I <br /> I CROSS STREET - -- ' <br /> T ; OWNER/OPERATOR 2 2��,�,n 00 � -----------------------------------------S1 ' PHONE # � ------------ <br /> C71: <br /> Y , "'�'1^�"v �w <br /> C : CONTRACTOR NAME S i PHONE # 4Jti <br /> o +------------------- <br /> N CONTRACTOR ADDRESS <br /> _�3L�1_5..�V 1.1���_'I Mf---------------------- -- LIC #Q�j�'/ -'-------CLASS <br /> 1 T +------- ------ _ ��J L <br /> -R ; INSURER �-�,�,�. -- ' WORK.COMP.# <br /> A ,- ---------_2!J RJ_Y--� Y1Q--------------------------------------------------+------------��- ---- ------- <br /> C OTHER INFORMATION <br /> iT +------------------------------------------------------------------------------------+----------------------------------------i <br /> 0 - - 1 PHONE # <br /> i <br /> R +------------------------------------------------------------------------------------+--------------------------------------- <br /> I PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # "1"I - TANK SIZE <br /> CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 1 39- <br /> 39- I <br /> +---.I3.9.- <br /> ...... I 1 ' 1 " 1 'I ' ' <br /> ! I „ , ... . <br /> P APPROVEDVADISAPPROVED) " <br /> A (SEEATWI Z IONS) y <br /> N 1 PLAN REVIEWERS NAME 2-�+'—rDATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J UIN COUNTY ESSSTATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> . FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCEOFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLEDATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> NameSr7-,V.2c;( Address rxsr CFS Ila- Phone # 1'SO& <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) \tvvcz .= ��e � -Vo _VeCSq;_ nom. <br /> L\ S� \T GUP-1 of �C.Cr �► - V:�1 c. 0�H(Ai+�r�..l �C,tZ T �J�c.\ S� <br /> �\'l0 Cr�,F'�C� �'Cs2J•�p'�J�sN� j�„47 V.��h� �'`yam ��-� �1. a�C�yT*JG:., <br /> S• ���•aer -.r�.+�,� ��v�� c�,vs\���-.n,��� �vz- �ac>"�t'� �vacwy�c.-�a,•-� <br />