Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209)468-3433 <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 <br />EPA Site # 0 <br />Project Contact & Telephone <br />A <br />C <br />Facility Name C ` <br />0 BOG <br />Phone # � <br />N - I+bb - X 51 <br />I <br />Address <br />T <br />Cross Street <br />Y <br />Owner/Operator / h ill i ncU r i�ja i_.r <br />Phone #O&q - 44-552 - occ7 <br />o <br />Contractor Name Etc c�Sl ' <br />Phone # ( , 4-61 - (63� <br />T <br />Contractor Address � <br />r, <br />CA Lie # �,(`�j'7� Class C�(�• H%� <br />R <br />A <br />Insurer �, I ©f <br />Work Comp # L ��(� ; `' <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />JCC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, uoc v2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ,gApproved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment Wi Conditions) <br />N <br />Plan Reviewers Name y t�1 Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN.000NTY, 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'SCOMPENSATION FOLLOWING: "I CERTIFY <br />LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE F COMPENSATION LAWS_ <br />THAT RWHIJC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER <br />THE PERFORM OF THE RK FO)IIA <br />O LI A <br />. _. _ � .. ' ..J <br />Applicants Signature_ �� V V` C Title Date <br />:.BILLING INF.ORMATION.........,.. ....... <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility f e billing byc,signature and date below. <br />NAME i'L�i�` �tt/U TITLE _PHONE# <br />ADDRESS 01 1 �' QJ�US <br />SIGNATURE 4 (j l/— f/ y <br />EH230038 (revised 08/1/11) <br />,I 2 <br />