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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW' <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT X UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone7/Y-31�z- <br /> A <br /> C Facility Name ��J��T ` �� F e, Phone#Gd9-� _j2 <br /> 1Address 22-5-u T/�q 9S"397 <br /> T /J <br /> Cross Street _ <br /> Y Owner/Operator �QST�� N — Phone# 'ela5--97Qd <br /> D Contractor Name <br /> Phone#D <br /> T Contractor Address CA Lie# 50cj � - Class - <br /> i0Z <br /> A Insurer �F. 'Ci1<111 / X�_� �Jp , Wo k Comp# <br /> cICC Technician's Name /fIlelL Expiration Date G- <br /> T <br /> o ICC Installer's Name /{0� �' Expiration Dace 4--09 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 10 87 piping sump,91 leak detector UOC 112.etcI Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N 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 HEALTH 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 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /,, <br /> Applicant's Signature Title /y�1' CG/�-Bate 2 <br /> BILLING INFORMATION, <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> lAld- <br /> NAME ./�/,f/O��d�if/i//P/J-1YJ TITLEONE#�i�/�7 /�•y/ <br /> ADDRESS O ZO l C_!/A'L11iILLVLt/E�9C17Y �l�C� C �/i0 Livi>��2 -tel' 9QG�,/ <br /> SIGNATURE <br /> --(CrZc' O s DATE�� �Q <br /> EH230038(revised 02/20/09) <br /> 1 <br />