Laserfiche WebLink
77 <br /> ENVIRONMENTAL =IEALTH C}EPARTMENT <br /> _---SAN -JoAQU N C0UN-nr:: . �ECEIVEC <br /> 600-East-Warn Street,Stockton, Cal-ifoWa 95202 <br /> Telephone: (209):468-3420 Fax:_(209)4683433 MAR 16 2015 <br /> — APPLICATION-FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIF'tNS3 REFi41R'"PERMIT ENVIRQNMENTAI <br /> --- --� ^7 I RMR IXPIRE5.180.nAYS FROM THEAPPRWAL OA TE INDICATE PERMITTYPE BELOW: <br /> QTANK.RFTROFR :D PJPING'REPAIR/RETROFIT O UDC REPAIR/RETROFIT DCOLD STARTIEVR UPGRADE <br /> Project.Contact.&.relePhona#- 1fY111L�11 <br /> Atldressi A . . <br /> m <br /> . ..T.: .Cross Street <br /> -yOwnedoperator .tU . Phpne# <br /> .o. -ContraGAor Name, \ Phone# 'Vi I <br /> T Cortractor-Ad' ss2 CA ue#6 Y'�(p class F .. <br /> .. .A . . Insu[er_ l9.'1 , Wprk comp# l v AJC) <br /> T ICC Technician's Name � - Expiration Date <br /> - --- R -ICCtnstaWs Name._ . . .. '.:_- E>Fpiration Date - - - . <br /> .. .. .. .. <br /> . Tank system work area Tank Size Chemicals Stored Currency . . Date UST <br /> h•sTrv�eaurc.Bl imk mlegor,t>tx+4 m) Installed <br /> T <br /> i.A - <br /> P. E Appixwed 4 Appm ed with conditions ❑Disapproved <br /> A 2 <br /> N Plan Reviewers Name Date J <br /> APPRM DCART MUST-PERFOAtL':WORK-IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIRGOUNTY;MVIRONMENI'AL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE F.QLLOWING:...:I CERTIFY THAT IN. <br /> THEPERFORWXPEQFIHEWORK FORWHICH-THISPERMITIS ISSUED ISU%NDTEMAU AttD'EEAtON.i0t CN A.MANW—R6$.T90ECOMESUBJEQ7To - <br /> _MFMCq�11SA77OWLAVWV FG`i�WCMPL' L�NDW(.'fOR'S HIRING.OR SUBCONTRACTING SIGNATURE CERTIFIES-THE FOLLOWING: 'I CERTIFY <br /> T4NTHE•PSRFORMANOE orTHEWORK-FORWHICN_THI"gftymg.ISSUKU:IP-W4._EMPG9Y,PE3Z,SQNS-SUBJECT TO VfDR1 R'a.CORiPENSA77QN tBW_5., <br /> 'MWfs Spulbe- llria Dab . <br /> I3ILLING INFORMATION:-._ - <br /> _.lndiG2te-tt7e-respoaslbi"rtylo-be-billedfier-add'dionai-EHD-siafFii91,Q eXpepded;beygnd perrtlit-payuNgsarragge_pgcYank;-If _... - <br /> --��` Ign e 'lielow_ - azL eperinh applicant,-e9 P�Per1Y-aAa7er, tne-paety-must=aBkrawdedge-iMs _... <br /> -. .NAm ri- <br /> - -SIGNATURE (�,�UEG <br /> 2 <br />