Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAKI 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 18C DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW; <br />D TANK RETROFIT ❑ PIPING REPAIRIRETROFIT © UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # (y-Z;;,G, f<1r,41jr2 9//, S'Z%9 <br />-3r: <br />A <br />C <br />Facility Name t� zl- U �, �, t t 'e %`l <br />Phone # <br />L <br />Address <br />I <br />Cross Street <br />Y <br />Owner/operator f • Phone # f 1-V 411�f 1 � <br />c <br />o <br />Contractor Name Phone # <br />f..2�c' � fly t� � , w'✓^ 'IC� <br />T <br />Contractor Address, f� �',,� j x . }r4 ,%r ✓ <br />CA Lie # f}y7 Class <br />R <br />Insurer r <br />Work COMP # 0.0 41e17 <br />TICC <br />Technician's Name ''� Cr �/�' <br />Expiration Date <br />R <br />ICC Installer's Name, ! ti 1 14 <br />Expiration Dated-���u,'5` 331'12 <br />Tank system work area <br />Tank <br />Size Chemicals Stored Currently <br />Date UST <br />(i.e. 87 plping sump, 89 leak detector, UDC V2, EtG.) <br />I n stal ied <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />r <br />Plan Reviewers Name M. of tv"- Date -7 �j 2- f Z <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: "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 Signature Title to t. Daio� �J <br />BILLING INFORMATION: <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 for the billing by signature and date below, <br />NAME c, �cs��'`/ �-/�C TITLE C�::� 7 G'/r3ir` PHONE#�r<, <br />ADDRESS Ji Ay <br />SIGNATURE DATE <br />EH230038 (revised <br />2 <br />2- <br />i <br />