COMPLIANCE INFO 1985 - 2003 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R0 FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT /_PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -----------------------------------+ EPA SITE # -------------'_--------- -PROJECT-CONTACT _R-TELEPHONE _# (XR!_ V:�- _�l I +------------------- F I FACILITY NAME I PHONE-#-----_____–____________________1 -!OSY mT�- ---- ��----------------------------- I ------------------------------------ _ADDRESS ---------- l 3 3(7_----_YO?_�m.{ _li�--------------------------------------------------------------------i L I CROSS STREET II +------—------------------------------------------------------------------------------------------------------------------I T I OWNER/OPERATOR I PHONE # I Y ► �2z rt . ---------------{------C--------,-------------------mac-97-"- a C I CONTRACTOR N�'� _\—, �.{_�� .Ic��—_✓_l___7_�_4C!!y J `_I PHGNE # Q„�G 7 J^ Q------ I O ----------------- , vim- __�v6 J_ 1 N I CONTRACTOR ADDRESS I, _ ^y� />. I CA LIC # I CI ASS I i I T +_____________________Y��_Q U T..J_!!_]__1_ 1_V__ _______________ __ A_ /_2__L_____________ ___________I r I R I INSURERI WORK.COMP.# A I-----------J_�h� o `e'i-c— _t ,�� _______________________+____________ t I C I OTHER INFORMATION I I +----------------------------------------I 1 0 1 1 PHONE # I ------------------------------+----------------------------------------I I PHONE # I Illlllllllllllllllllilllllllllll---------------------------------------------------------------- -----------------------------I 1 I TANK ID # 1 TANK SIZE 1 CHEMICALS STORED LY/PREVIOUSLY 1 DATE UST INSTALLED 1 I 39- T 39- I I I I A 1 39- I 1 1 N ; 39-_ I I I I 1 K 1 39- 39- 39- P 9-39-39-P �l I L OVED _APPROVED WITH CONDITIONS) DISAPPROVED A 1 \ (SEE ATTACHMENT WITH CONDITIONS) DATE N I PLAN REVIEWERS NAME +___111111111111111111 1111 11111 111 II IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII111111 I I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 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 I ! BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRAC'TOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I 1 I 1 r APPLICANT'S SIGNATURE: TITLE DATE - 41"r- - -- - - - - - -----------: BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Se rU',cC� 5 Q, — Name �� L1u� ---------Address (0�6 � r----------Phone # ------------- CK_ �P4 Cir" , 9 S 1! gi-