Laserfiche WebLink
SA N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 18D DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # 66 0 7S�6 SSZ Project Contact & Telephone # Cva k1.. C C,4" e4C Z(9Li <br /> A <br /> C FacilityName t ` S e CL) 001 Phone # LZog pay 6 q g y <br /> L Address /ADO SG. 1Vq S -f A4 Rix 4eC4. CA 53 ? <br /> T Cross Street ^ �,,� , Park f <br /> Y Owner/Operator �o S4 e Ck e C!4 Phone # C2 pct a' ZS- 6 8 y <br /> Contractor Name I � GIoI ✓ � ( �o p - 0 <br /> T Contractor Address kI vt C fiGC CA q fj6;q CA Lic # 57 Ll it Class A <br /> AInsurer J l C Cum G,v�3ci ;r , `1'�'13Vra•-� a r�v.A j Work Comp # �- <br /> T ICC Technician 's Name Cnv a Aa r v a e G z Expiration Date <br /> DICC Installer's Name �' ( x Date <br /> R � vaC�.a v t CL �. CInt 2 Expiration ZO2 1 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1n, etc.) Installed <br /> T . , 2d k g - 1 - 195 <br /> N o-� 2 12 - 1r1 9 <br /> K ark3 `'i 1 to k 91 <br /> P ❑ Approved ,❑ Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions) <br /> A / <br /> N Plan Reviewers Name_ 1 / / <br /> 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 AGENTS 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: "1 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.' /� / c <br /> ApplicantsSignatu «4 Title C , 4,4a � 7 �.� Date <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 <br /> billing by signature and date below/. /� t� <br /> NAME,Y1; {646M ! G � �NM �cr�� a, 51, TITLE t� 4rae ice/ PHONE # tgZ f1 7,/ 4O - O fO3 <br /> ADDRESS�c� 7 /t / h (' �7� /�►yl T1OC �� Y �C� <br /> SIGNATURE � DATE <br /> 2 of 6 <br />