Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> - - COUNTY --- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT PIPING REPAIR/RETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # it' d emir. s / S oa "U <br /> A <br /> O Facility Name1 Phone # <br /> Address S� 00o <br /> L 3SIS �V ► v � � � SZa <br /> I Cross Street LONJ \Wf4rl L1 oa <br /> T <br /> Y Owner/Operator Pro %0c,1's Phone # q1t _ 951 _ OaSJ <br /> C Contractor Name T Phone # <br /> o � � tiv � ra rr� � ,. i rvV wt � / _ S v � �� <br /> T Contractor Address I'd (iM r. CA Lic # Class AZ <br /> �� 1 � � s �,,� � /Sti , S &$o5 B Glo <br /> A Insurer Tr&V .L� r 'r Fro C l } (,o 64 LVr ) L1 Work Comp # V13 . 4JS 3` 4?1 4 4 <br /> T ICC Technician 's Name � a� L � tL� o SZs �-1 � � Expiration Date <br /> R ICC Installer's Name �� N (r j Expiration Date 1 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> P,(i .e . 87 piping sump, 91 leak detector, UDC 1 /2 , etc. ) / Installed <br /> T f iN < Wb. . 6 <br /> A IF <br /> N It�f s � .t ► f � e V� vcy., t 1 <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L e ttachment With Conditions ) <br /> A <br /> N <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD 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 W K F R WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> � 1 <br /> Applicant's Signature Title Pro d /" to Date II hT 1Q <br /> V 47 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below is different than the permit applicant , e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and dame below. p <br /> NAME Tz ,-� �. . trowu .r � i � TITLE brio., yri .. L . /I )I PHONE # 71 y <br /> ADDRESS '761 NorK lt _'D� / Drfvt Js.�La / N�. 2 y GA IZ �7Our <br /> SIGNATURE DATE <br /> 2 of 6 <br />