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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT IXPIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# b ou le- $m w-iry 447 GG-r i <br /> � Facility Name N l p Phone#a�_ 7-60 2( <br /> � Address qSacxs <br /> Cross Street <br /> T <br /> Y Owner/Operator 5.g.N Phone# <br /> C Contractor Name Phone# _3 <br /> ry Contractor Address l ,p Sr- I CA Lic# 'ri'74Q102 Class $-Dv, W4 <br /> R Insurer r%b►J AP`i WbeN P-o Work Comp# <br /> A <br /> T ICC Technician's Name ,j7l+rs �Y-rou S 2 07(o l.(, Expiration Date C9/7 2/y!r Z <br /> R ICC Installer's Name Sxnryg Piy1vp TGG" 51L '7&�iG Expiration Date OT 2,7/'�lZ <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.67 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T ,1104 'Dy"FL -nwv_ 11-9011- "Zp M ct0 <br /> A P�i'f�fJfafL <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Atthment Conditions) <br /> A // /� <br /> N Plan Reviewers Name Date J� G Q ' ' <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORIANX WITH SAN JOAQUIN COU TY ROMANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED GENT'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 <br /> TO 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 Dale <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. �r�� � <br /> NAME �F y &- PR35£S/ARZ TITLE &7WIrK -'ro fL PHONE#C2-,5-, 107 "�f"Boa <br /> 46 <br /> ADDRESS 237/OM\A'��'.azo G/3,Tf-L:5 Q- LObCA 9S-ZS-o <br /> SIGNATURE l //-fir a // DATE <br /> EH230038(revised 02/20/09) � <br /> 1 <br />