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 # Ka--6 a �( <br /> A Facility Name Phone <br /> I Address 3 49 VockhLACA Isailb <br /> I Cross Street <br /> i <br /> TPhone # a ©`T — <br /> Y Owner/Operator �3uVa&6 <br /> C Contractor Names� k� S' j S },e1,I,lT �, Phone # q6 -�( 3— �O3p' <br /> N Contractor Address 4� % b V; k� CA Lic # G pi; wl k 4 Class j CjQ ( j t <br /> T <br /> R Insurer Work Comp # <br /> A <br /> o ICC Technician ' s Name � eeSQLQt�� Expiration Date <br /> T <br /> QICC Installer' s Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date kz 7 s-1 <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 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signaturela 0LLL(o C ' V r 4vktc��wL4 L � Title V 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 billing by signature and date below. /fir <br /> NAME rL�l W t l � 1 � � '> i TITLE &LI"l1ta 'e PHONE # <br /> ADDRESS `� O � l} LL1�- SQ �I ID �- `.' ' <br /> L3 �D6 <br /> SIGNATURE I (>< .lr'..w � " • DATE <br /> 2 of 6 <br />