Laserfiche WebLink
09/18/2006 09:16 2094683433 EHD PAGE 02 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue, Third Floor, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TMIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> "TANK RETROFIT -PIPING REPAIR/RETROFIT OUOC REPAIR,'RETROFIT <br /> F EPA Site 7i C 114 cc �t xd q} ) 30 Project Contact&Telephone# �rT,,,1„��ards 4 5•�1 b <br /> C i Facility Name �n n Phone# to(o_OZ 03 r <br /> irAddress DJ5M W Lr-. Lo Ha _� Lc�� 7 � -- <br /> 1 cross street <br /> y Owner/Operator V�rS-�— rji N D Phone# C5 a _ aco-- -� <br /> C contractor Name Ls�roha C �rtS ,/ltc Pone# gt7g b3Q (0711 <br /> N Contractor Address(9 1 S E A n HL TQ .LSOLn Di trioti CA Lic# -7 q-7 L4 55 Class 11- g }q <br /> A <br /> Iluurer I ���d—_— T_ Work Comp# 1'ICC Technician's Certification Number Expiration Data -� <br /> R . ICC Installer's Certification Number 5 Xb0 -41 Expiration Dete <br /> - j Chemicals Stored <br /> Tank ID# Tents Size Date UST;nstafled ' <br /> _ CurrenUy/Previously i <br /> T 100 Prern;Urn Q[ <br /> iA 06173 1 5co75ote o3 a 000 T <br /> N <br /> K <br /> I -- <br /> P 1 JApproved CApproved with conditions FIDisapproved <br /> L (See Attachment With Conditions) <br /> A ' <br /> N I Plan Reviewers Name, Date_ _ <br /> APPLICANT MUST PERFORM ALL.WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL MEALTH DEPARTMENT,OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUi TO I <br /> WORKER'S COMPENSATION LAWS Of CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE POKFORNIA14PS OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I S L EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS , <br /> OF CALIFORNIA" C� <br /> Applicants Sipnatu rillIAA_ Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional END staff time expended beyond permit payment coverage per tank. If <br /> the parry designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility fArthe billing by signature and date below. //�� � t�IC (� �y J <br /> NAME C) {-�NLPQZ. TITLE IAA rrl i t.(• r_JSS4_ PHONE# zbsI �I�"]o10 �dUa1 <br /> ADDRESS�oS hcha �n lid . w r k g/33-� <br /> SIGNATURC��, F Q,- <br /> EH230038(revised 8/x106) J <br /> 1 <br />