Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3R°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 /> +----- ---------------------------------------------------------------------------------- --u------------ ---------- <br /> EPA <br /> - - - - -- -----/--�J-+ <br /> EPA SITE # ; PROJECT CONTACT & TELEPHONE-#-KATHY 5il ij N-C3�O�3,Z3-47 <br /> +--------------------------------A--/--------------------------------------- - --------------------------- <br /> F <br /> - - <br /> F ; FACILITY NAME --4t� sr6. ; PHONE_#__ 2 9 66- 61,633 ; <br /> A ----------------- ------------ - ---------------------------------------------------- <br /> -------(----- -`�------------------ <br /> C ; ADDRESS 1940 <br /> II +------------------------------ ---- -- ----------------------------------------------------------------------------------- <br /> L ; CROSS STREET //fj�C��� X--- <br /> T OWNER/OPERATOR ��WeS //O�J GGC PHONE # <br /> Y ; (")SZ s" SgS7xf 6233; <br /> I- -+---------------------- - -----/--------- ---------------------------------------------+- -----------j-------------------------; <br /> C ; CONTRACTOR NAME C�r'/e S G , Tho rvv-- s 6o. PHONE # ��j/O ?j2 3��p7?jO SGT Z ; <br /> O +-------------------------------------------A-------/�---- -------------------------------------------------- <br /> -------------- ---------- --------- ----------------1 <br /> I N CONTRACTOR ADDRESS I37o� Si I��n7it �7'v+2, /,� � � yaZ4�CA LIC # �ZQ/� : CSS O <br /> IT +----------------------------- ------------------SS/, - - - ----- <br /> R <br /> - - -�---- f---- -� <br /> I R I INSURER -- /�------------ ---------------- ----- - - -- - <br /> WORK.COMP.# ' <br /> S �Ft Fuv► <br /> C ; OTHER INFORMATION <br /> T +------------------------------------------------------------------------------------+----------------------------------------1 <br /> 0 ; ; PHONE # <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # „ TANK SIZE ; CHEMICALS $TORED CURRENTLY/PREVI USLY ; DATE UST INSTALLED <br /> 39- ��NKN0WA) 12,coo OnleaQed Ga // <br /> sone- ew7) 1)NiC4.,04VA-1 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- 12_0 lt,r, UA IeacieA 49/ VW441DWAI <br /> 39- <br /> 39- <br /> P ; <br /> L I APPROVED V APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ; SEE Ate. TTA,FHMENT WITH CONDITIONS) /�-;4 <br /> N PLAN REVIEWERS NAME /II�.IJ DATE GY' <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 /> �(j�/ /3 04 <br /> APPLICANT'S SIGNATURE: TITLE /�� ��-" '��54 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 <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 />