Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3H FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> TANK RETROFIT_PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROF T <br /> ---------------------------------------------- <br /> p r ( ` C C <br /> SPA SITE » 13 ----- 3 PROJECT C(%1'1'Al'1' 6 tELBPHONB Ny\n _GPdV -JS .IG{(11_52�J:{J /�6_• <br /> P FACILITY ---- (JS N --- ---____--___-__ ____________________Y__s_t___ PHONE » r QJ Y✓_ J O_L <br /> LT 1Tu <br /> A ._________ _ <br /> I ADD-Ess $L7L7 l.�-_L a�•-- 1 uo . CA n C� I <br /> Op� ----------------- ----------------------------- <br /> L : ----- --sear 041Q__ �](AC_Y' Q -b <br /> -- ------------------------------ <br /> ,' Y I OMNI/ PSRATOR n PNONB M __________________________ <br /> ---•-------� X54_T427 va_►_e_Lt_r1 C.� l-1 _-I (1_71118(06-9a -------------' <br /> C CONTRACTOR NAME �S�I �`��[f`c�f�-fA ]__ I�aAI ----------------------------------------'-PEONS » <br /> D -------------------- //I�,, p1 =----9-----�Qr�Q�_� �P_ <br /> N CONTRACTOR ADDRESS �a(DI E• `I+h 5}__ _ -------------- ----- <br /> LIC N 48,51s9________CSS___ <br /> T i____________ _ _ _ <br /> R INSURERI_ _�n54 ?_d_ - <br /> L _ ________________________________________________i ■OR-.COMP,- /C`(�_______________ <br /> __________ <br /> C OTNR - ATI-- <br /> : T i_________-_-_-_-_-_______________ <br /> __________- <br /> O <br /> g i______________________________________ P--NE: It <br /> ----------------------------------------- <br /> PHONe N <br /> „39- -II:: <br /> TANK D M 1 -TAIeH�R^SIZe C MICATS STORED CD MLY/P-RVIOMLY : DATE DST I-STAL <br /> T 39- ._.. <br /> N OL I <br /> 39el <br /> - <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39- <br /> • - B1L® APPROVED WITH NNDITION(SI _ _ DISAPPROVED <br /> III II '. •.x (586/ATTACHMENT XITH COHOST y� <br /> A IONS) <br /> N PLAN REVIEWERS NAMfi DATE .. b <br /> APPI,ICANT MUST PERFORM AL:, WORK IN A WITF SAN JOAQUIN COUNTY ORDINANCES, STATE :.AILS, AND ROLES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT OXNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORN POR MRICH THIS PERMIT IS ISSUED, I SHA:.:. NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION :AMS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOL:.OWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION :,AWS OF CALIFORNIA.- \ <br /> APPLICANT'S SI(itD1TUR4J _ TITLE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> NaMOC//11 <br /> �� �� \ <br /> O 'A NQz, Address 01 FauJ Phone /8 $� Q� <br /> _ ruour0. .), / J/ <br /> Signature I dy� 2� 3 <br /> n I I <br /> I <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />