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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> GTANK RETROFIT L r,.'1 (1I Z� <br /> F EPA Site# Project Contact&Telephone# t� l <br /> A Phone 69c- <br /> C Facility Name <br /> L <br /> Address <br /> TCross Street 1� Phone# <br /> Y Owner/Operator ` `J <br /> Phone#��(, , <br /> c <br /> Contractor Name Wt <br /> o <br /> N CA Lic# Class A <br /> T Contractor Address �� G lltw r, t�WL <br /> R .Work Comp# <br /> A Insurer C,. com <br /> C �� Expiration Date <br /> T ICC Technician's Certification Number to ` t) U 1 <br /> o [0QC �j E piratio ate <br /> R ICC Installer's Certification Number <br /> Chemicals Stored ate UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> 0(UO A 1 <br /> T <br /> A 2 (A) <br /> K V "� <br /> P, ❑Approved Approved with conditions ❑Disapprove <br /> L (See Attachment With Conditions) <br /> A /dam <br /> N Plan Reviewers Name Date <br /> APPL1 CANT MUST <br /> F SN <br /> OAQUIN COUNTYPEERFORM ALL K IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND NV RONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED GENTS SIGNATURE CERT F ES THE FOLLOWING:REGULATIONS"ICERTIFY TOHATATO <br /> IN <br /> THEWORK RSOCOMPEN OF THE WORK FOR WHICH THIS PERMIT IS <br /> COMPENSATION AWS OF CALIFORNIA.- CONTRACTORSDHIRI G OR SUBCONTRACTINGRSON SIGNATURE CERTIFIES I SHALL NOT EMPLOY ANY IN SUCH A MANNETHE FOLAS TOBLOWINGS"IBCERTIFYY <br /> THAT IN THE PERFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNI Title r� Date Z.q O <br /> Applicants Signatur <br /> :� tl� <br /> BILLIN I ORMATION: <br /> Indicate the responsible party to be illed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is differ than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> PHONE <br /> NAME U� ^-' TITL I V 11t <br /> ADDRESS I't <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br />