Laserfiche WebLink
• 0 <br />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 <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name morfjaC-Ac rr <br />Phone # q3� <br />I <br />L <br />Address <br />01F_?'Al l �w T I (fA OS72—/ Z. <br />TCross <br />Street F� <br />Y <br />Owner/Operators �- <br />Phone # 7� --� yr <br />o <br />Contractor Name Aj C_ /mss <br />Phone # 70d _2 5 <br />i 7— x/ P f <br />N <br />T <br />Contractor Address <br />7 1.6 n "r-- - L �bc 9 j <br />CA Lic # Class <br />�% � � -9 <br />R <br />A <br />Insurer <br />Work Comp # <br />CICC <br />Technician's Name s , t,I <br />Expiration Date I <br />R <br />ICC Installer's Name k", r z ; S <br />Expiration Date <br />Tank system work area Tank Size <br />Chemicals Stored Currently <br />bate UST <br />Installed <br />(i.e. 87 piping sump, 91 leek detector, UDC 112, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ,-;�i'Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />'611. <br />Plan Reviewers Nam Date / <br />APPLICANT MUST PERFORM RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONHEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />�ZR <br />THE PERFORMANCE OF THERK FOWHICH 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 />61n13 <br />DDlicant's Sianature Title Date e�✓ -,� /� _ <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. p / <br />NAME_ L1 alt 1 TITLEGr�J n PHONE #� <br />ADDRESS / J �?� l /J(,,j 7 <br />EH230038 (revised 0811111) <br />2 <br />DATE CYC <br />