Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN°COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone: (209)468 3420 Fa$: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYpEBELOW: <br /> DTANK RETROFIT ]PING REPAIR(RErROFrr I GuDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact A Telephone# <br /> C Facility Name lSJ F� <br /> L Address <br /> I/ Phone <br /> I <br /> T„ Cross Street . <br /> Owner/Operator <br /> Phone# <br /> o Contractor Name:', <br /> Phone:# <br /> -Nr Contra dor Address , XI .CA UC' #�(p Class <br /> A SR S t Insurer - <br /> Work Comp# _O <br /> T ICC Technician's Certification Number <br /> . .O Expiration Date <br /> R - ICC Installer's Certification Number <br /> Expiration Date <br /> E <br /> Tank ID# Tank Size Chemicals Stored Date UST installed.. <br /> Currently/Previously : <br /> T <br /> N. <br /> P unpproved proved with conditions <br /> Disapproved <br /> A : (See Attachmewith Conditions) <br /> N Plan Reviewers Name Date J fti Z 2d <br /> _- <br /> APPLICANT <br /> MUST STPERFORM ALL WORK IN ANCE H SAN JOAOUW ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMENTAL HEALTH.: ARTMENT.OWNER OR.L AGENT'SSIGNATURE CERTIFIES-THE FOLLOWING: 'I CERTIFY THAT IN <br /> . - <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUF=D,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNERASTO BECOME SUEJECTTO <br /> WORKER'S:COWENSATION.LAWS OF:CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY <br /> 771AT M THE.PERFORMANCE OF.THE WORK.FOR"WHICH THIS PERMIT D ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS- <br /> . OF CALIFORNIA:•.- - <br /> AppricanW S]gnaW. ." <br /> BILLING INFORMATION: <br /> Indieate.the responsible-party to-be billed for additional EHD staff lime expended-beyond permit payment Coverage*tar*. if ' <br /> the-party-designated--boldw-is-ddfereot than the permit applkxnt e.g..Property owner,the party must acTmrWedsge this <br /> responsibility for the billing by signature and date below. p " <br /> NAME �,►m (1)t yarn (� TiTLE F�1 U SC ttkt}i V ; '.P.HO�NE# <br /> ADDRESS <br /> SIGNATURE_�'lIl-kVA►�t <br /> EH23DO38(revised e/&06)' <br />