Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3f�O 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 REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />------------------------------------------------------------------------------- <br />---------------------------- <br />+----- <br />EPA SITE % ; PROJECT CONTACT 6 TELEPHONE % - 4 q� • 3� ' <br />v L <br />F ; FACILITY NAME 0 Q C _ O ; PHONE % <br />1 C -- r --I t <br />C ; ADDRESS 1 ��Lj --- ` `' �V-�-- (-,j <br />A y�--------------------------------------------------- ----------L <br />I+----------------- , <br />1 L ; CROSS STREET <br />T ; Op <br />OWNER/OPERATOR PHONE % <br />Y 1 B (.,u ES Co ASS �•.� D. c—, tL `1 14 X70 a� <br />------------------------------------------------------------i ------------------------------------ <br />C ; CONTRACTOR NAME C L ' PHONE % - <br />S. J f� c A �; Q ti a c , � A, -` S E� SSU - $ � S ------------------------------------ <br />, ----- <br />T+ CONTRACTOR ADDRESS i � v S A�_ H �`��,('_ - LIC % 11-�.�----_----- HAI} R-, H(_L`__--- <br />R I INSURER J' A lv\-2 J �' ; WORK.COMP.%q b 1 bUUU 451 d3 1--- -------------------------------------- -- +-------------------------------------- <br />AC ; OTHER INFORMATION ' <br />T---------------------------------i- <br />I 0 1 ; PHONE % <br />IR ------------------------------------------------ -------------------------------- +-----------------------------------+- <br />1 PHONE % <br />__ _ __ <br />-----------------------------'-------------------------- -- DATE UST INSTALLED '---- .r <br />" TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY <br />TANK ID % � ' <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />... <br />P <br />L AD -ROVED _APPROVED WITH CONDITIONS) DISAPPROVED <br />A E AT ACHMENT WITH CONDITIONS)' <br />N ; PLAN REVIEWERS NAME 29 DATE �� , , , , , , <br />APPLICANT MUST PERFOR,11 ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JCACUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTEFYTHAT IN THE <br />PERFORNTutlCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY A19HS®N IN SUCH A MANNER AS TO <br />BECOME SJBJECT TO WORKER'S COMPENSA?ION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLCWING:"I CERT:FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECTITO WORKER'S <br />COMPENSATICN LAWS OF CALIFORNIA." ' <br />,.,T 6 > 2 ) 9 <br />APPL=Z�:;T'S SIGNATURE: TITLE A G Q DATE <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name Address <br />1 <br />Phone # <br />