Laserfiche WebLink
r <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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW- <br /> El TANK RETROFIT"� PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT LD START/EVR UPGRADE <br /> F EPA Site# - Project Contact&Telephone# <br /> -Facitme <br /> ily Na ���,,}n�V Phone <br /> - AddressCA <br /> TCross Street. <br /> Y:- Owner/Operator <br /> p. Contractor Name - Phone# <br /> T -Contractor Address A LI # Class <br /> R.'- InsurerA- ? �+1� - n Work CoCrrtp#� �' 'WG 1— <br /> C ICC Technician's Name - <br /> T- Expiration Date <br /> D ICC Installer's Name <br /> R - Expiration Date <br /> Tank system work area - - c - - - Date 1IST <br /> Qs.67 POV P.91 b k0ebcay.UDC 12&c) Tank Size "Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> �- 'P - ❑ Ap ved roved with.conditions <br /> L. P ❑. Di approved <br /> L ee Attachment With Conditions) - I <br /> N Plan Reviewers Nam - Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN WOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN <br /> ,THE PERFORMANCE OF-THEWORK FOR WHICH THIS:PERMIT IS ISSUED,1 SHALL-NOT EMPLOY-ANY-PERSON'INSUCH AMANNER AS TO-BECOME SUBJECT <br /> - TO-WORKER'SCOMPENSATION LAWS OF.CAUPORNIA.*CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR.WHICH THIS-PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPEN SA71ON LAWS <br /> OF.CALIFORNVL' t(om�+.,, <br /> Appli..fs Signaivm Date vl Q —10 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permitpaymentcoverage per tank If <br /> the party designated below is different than thepermitapplicant'.e.g. property owner;:the party must_acknowledge this <br /> responsibility for the billinng...b�y�signature and date below. q��-p�t�C Yin- - - <br /> NAMFEI kJ IT UI Il7Q` L 1 I i TITLE T ESj ��I rlll Vu PHONE�?� l <br /> ADDRES$_L.1_lLltil VLLILI'YV.ITIIl [� IU��T �e� 'I lJ GC1� <br /> SIGNATURE ATE-2010 <br /> EN230038(revised 02120/09) <br />