Laserfiche WebLink
06/13/2000 11:45 2093651543 TANKNOLOGY PAGE 01/05 <br /> ENVIRONMENTAL ,ALT <br /> SAN JOAQUIN COUNTY <br /> 600 Ernst Main Street,Stockton,California 95202 <br /> Telephone:(209)468-3420 Rax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR P RMIT <br /> THIS PERMIT EXPIRES 80 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE eELOW: <br /> I ITANN RETROFIT OPIPM REPAM11TROPIT DUOC REPAgMRETROFRT <br /> F EPA She# PMJ*d Contact&Telephone# <br /> A Facility No I M „S ra PDO-7 Phone III Z07-461T?-I/ . <br /> I <br /> L Addreas I (a f hl, G[. 4 o"E. R al. or G4 tQ(o <br /> T Cross street ' <br /> Y I OwneNOperatar .Phone# ° <br /> C Contractor Norrie l �N�, Phone# <br /> T Contractor Add r@as (L L ra W. I ®ort 1.A1 CA Uc#7y3/iii 0 crass <br /> R Insurer qn IC L ( 46100,01&414 W,6 Comp# Ito b'ut <br /> C ICC Technician's CeAftation Number Expiration Date <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# TW*Size Cheml=ls Stored Dote UST Insjled <br /> cuffentwPreviously <br /> T ! <br /> A <br /> K <br /> P I.!Approved EIApproved with Conditions I..IDlaapproved <br /> A ith(See Attachment WCordons) <br /> N Plan Reviewers Name Data <br /> APPUCANT MUST PERFORM ALL WORN IN ACCORDANCE WITH SAN JOAQUIN COLINTY ORDKANCSS,STATE LAWIL AND RULES AND R�th.ATIOt�i. �SAN <br /> JOAQUIN COUNTY. ONMENTAL HEALTH DEPARTMENT.OWNER rat LICENSED AGENTS SIGNATURE COTIR65 THE F �CERTI THAT IN <br /> THE PERFORMANCE OF THE WORN FOR WHOM Tits PERMIT Ie re I SHALL MOT EMPLOY ANY PERSON IN 6UCN A MANNER AS YO BECOME S CT TO <br /> WORKEITS COMPENSATION LAVA OF CAUPORNA." CONTRACTORS HIRING OR SUPPONTRACTING SIGNATURE CERTIFIES THE POLLOWIN is I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSLVID.I SPRAWL EMPLOY PERSONS SUILIECT TO WORKERS COMPENSA11ON LAWS <br /> OF CALIFORNIA." <br /> Apioftems 8 eawe TNI Pae ° <br /> 71 1811-1-10INFORMA ON: <br /> Indicate the responsible party to ba billed for additional END staff time expended beyond permit payment coverage per tank'If <br /> the party designated below is dtlTerent then fits permit applicant, e.g. property owner, the party must acknowledge 11�e <br /> responsibility for the billing by signature and date below. <br /> NAME TITLE PHONES <br /> ADDRESS <br /> SIGNATURE , <br /> CH230038(revised 813/07) <br /> 1 <br />