Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"0 FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT NPIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> �---------–_-------------------________ __ ________ ____________ - __________- _______–___–_________- <br /> ; EPA SITE x ; PROJECT CONTACT 6 TELEPHONE x C J' <br /> ---—-------—----------------------------—-----—-----—-------------— ---------------------------------------r 17uv Z09-SPl--- <br /> G �f — J9 --- -----' <br /> A FACILITY NAME__–J%M«J___!!�I_�C1_--NT T_ –---------------–_–__–____ <br /> C ADDRESS 400 <br /> L CROSS STREETWy <br /> — y <br /> PHONE <br /> T OWNER/OPERATOR I�' n---- — �'L <br /> Y (f <br /> FEoHE <br /> I'P <br /> z <br /> ------------ Y---- P --------------- °p' Q=ziiz - <br /> , <br /> C : " <br /> NAME DOSM� - ___________–_____— <br /> Q p - _ Nc �JJ11 /a /� <br /> N CONTRACTOR ADORES=ZO. R_I/Z �-4yc,_:, {Y,I cT /J3q_/LIC xY �l ns9 CLASS <br /> IW <br /> R INSURER woHx.0 .x <br /> A _' <br /> C OTHER INFORMATION <br /> T --------------- –---–---------–--------------------------------------------–___-_ ________ _I <br /> 0 ; ; PHONE x <br /> R —------------– i-- <br /> , PHONE x <br /> ---------- ----—________________----_— <br /> TANK ID x TANK SIZE ', CHEHICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED , <br /> 39- <br /> T 39- <br /> A 39- <br /> 1 39- <br /> K 39- <br /> 39- <br /> 39- <br /> ;'1 _' <br /> P <br /> L f "11 APPROVED APPROVED HIM CONDITIONS) DISAPPROVED;' <br /> A (SEE ATT3�(',{ T�.'T WITH CONDITIIXQS) <br /> N ; PLAN REVIEWERS <br /> APPLICANT MUST PERFOMIII ALL RORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE IAHS, AND RULES AND PEGULATIONS OF ii <br /> SAN JOAQUIN COUNTY, ENVIROFAtEN'TAL Fff M DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK MR MICH THIS PERMIT IS ISSUED, I SHALL NOT EMPIAY ANY PERSON IN SUCH A FANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: ^I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO i 4ARKER'S <br /> COMPENSATION MAWS OF CALIFORNIA///^J��.-r�(¢/,/����/��� <br /> ; APPLICANT'S SIGNATURE: �{p ¢y'y�a TITLE 1942t A DATE 9 z?-oy <br /> t_________________________________ _ __ _____ __________________----______-------------_---------- <br /> ___ ____–_________ <br /> I ---Sc44Jl¢, 4n 4?09aifv "-+- w �-(�( Hr'S Ad" '-A- <br /> BILLING INFORMATION: WW' � �r'(v A'd, lwt- dui 4"'f-� <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name JT, Aco Truck. Ndtaq Address /02.z `-in,441E �. j '140f) Phone# 009-519-0/f2. <br /> 1 <br />