Laserfiche WebLink
r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD 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/RETROFIT <br /> +------------------------------------ ----------------------------------------------------------- -------------------- -----+ <br /> EPA SITE-# 1 PROJECT CONTACT & TELEPHONE # b& _ts C - ?j?j- - <br /> +--------- -------------------------------------------------------------------------------- ----------- - ---- 2(d <br /> A � 3 <br /> F 1 FACILITY NAME Mv\9kC,kPA� 5 9-qL� "N , PHONE # 333 --_____10 <br /> IA +------------------------ ---------- ----------- ---------------------------------------------------, -------- <br /> C I ADDRESS ,31�( 5_ � �� <br /> I +------------------- 1 ---- ---- ' --"---------------------------------------------------------------------------------- <br /> L 1 CROSS STREET------_ L _- _ ' <br /> L� 1�L �31�"� ----------------------------------------------------------------------- <br /> T I OWNER/OPERATOR C,,� O� r _ , PHONE <br /> Y �p 77 1v C Y� i <br /> C CONTRACTOR NAME- 2 ism �v ��------------------- -- PHONE-# <br /> N i CONTRACTOR-ADDRESS ? -� ---1 /t/�--�-X006- ---CA_LIC_#_7(�_p-fl� '---------CLASS ------' <br /> T +----------- J LL��-- 1� �J. -111 <br /> RINSURER ,I1�------------------------------------------------- ----------- '�_1 V......1--------------I <br /> C ( OTHER INFORMATION <br /> ' T +------------------------------------------------------------------------------------+------------------- --------------i <br /> 0 I ; PHONE # <br /> , <br /> R +------------------------------------------------------------------------------------+----------------------------------------' <br /> i <br /> i <br /> PHONE # <br /> +---ill�l��1111111111�1' „���III� ---------------------------------------------------------------------------------------------- <br /> TANK ID #�I TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> I N 39- <br /> I K ; 39- <br /> 39- <br /> 39- <br /> I P I <br /> L /^ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ; / -- ATTACHMENT WITH CONDITIONS) <br /> DATE 9 O <br /> N ; PLAN REVIEWERS NAME <br /> -X <br /> +---.I.........„ I II11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "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 LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DAT <br /> ----------------------------------- ------------------------------- - -------------------------+ <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 /> Name Address Phone# <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />