COMPLIANCE INFO 2005 - 2015 - Laserfiche WebLink

Home Browse Search

M of SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3PD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR(RETROFIT +_______________________________________ _ 1 EPA SITE q 1 PROJECT CONTACT & TELEPHONE R _______ I A ---------T- NAME - �i/ -1-_---- 1 : ADDRESS IDRESS----"---- 1 L CROSS STREET 14-(Lly qP 1 I ----------------------------------------- T I OWNER/OPERATOR Y ------------------------ -----___ C CONTRACTOR NAMEV l�11C 0 + ______________ _ n-'_____ L N CONTRACTOR .ADDRESS 6.7 � �F! C_c�CPP T------------------------- R ____ ________R INSURER C OTHER INFORMATION T----------------------------------------- 0 ' ----------------------------------------- ---------- TANK ________TANK ID q 39- T 1 '39- A-1 39- N 39- I K 39- 39- 39 - P L 1 APPROVED' 1 A / N PLAN REVIEWERS NAME APPLICANT MUST PERFORM ALL WORK IN ACCORD SAN. JOAQUIN COUNTY, ENVIRONMENTAL HEALTH THAT IN THE PERFORMANCE OF THE WORK FOR W BECOME SUBJECT TO WORKER'S COMPENSATION L FOLLOWING; "I CERTIFY THAT IN THE PERFORM WORKER'S COMPENSATION LAWS OF CALIFORNIA. APPLICANT'S SIGNATURE,"' ----------------------------------------- BILLING INFORMATIOW: rV& ( f Z I PHONE k / �. +-15f— ZS.1 3. 1 ____________________________________________i_________________-________ 1 ___________--- PHONE 9 ------------------------------------------------------------------------------------- _______ _ _______ ______ _____NONE - __ l -_--- __-______ � -- ---- LIC k -- - -11 -_1))(F.-- I CLASS I _1 - - --------- 3N Z3`tC, - , _________________ , -' PHONE # 2 11 3I -E ____ ______________________________ - }DDDR DDDR------------------ --------- PHONE 8 I TANK SIZE CHEMICALS STORED CURRENTLY PREVIOUSLY DATE UST INSTALLED CONDITIONS) , DISAPPROVED - H CONDITIONS) DATE �/ ZQ 1 , E WITH SAN JOAQUIN COUNTY ORDINANC S, STATE LAWS, AND RULES AND REGULATIONS OF ARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY H THIS .PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE E OF THE WORK FOR WHICHTHISPERMIT, IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO TITLE., ('J/(i. i��/(: ,. �."S< DATE ------------------ Indicate the responsible party to be'', billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below.