Laserfiche WebLink
ENVIRONMNTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> !V TANK RETROFIT PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# I&VO y Qet)w,v /6 P29 4 82 P <br /> A <br /> C Facility Name A 1 &6 Phone# .20ct4/ 649 16/ <br /> 1 Address 3 12 A <br /> TCross StreetL <br /> Y Owner/Operator Q PIAIU-0 Phone# SO3 5'2 q 4)q l <br /> C Contractor Name Garnc-2_ ,.1 Phone# �2,j^S`f/ '�S,f�j <br /> N Contractor Address <br /> T G 7-6/7 S/FQ/rA Ov27- SV TFT CA Lic# 2 93 Class qyV ryt,t cro <br /> A Insurer STAT6 CoAp IAISVgC- Fu/vWork Comp# y2 P-.2co y <br /> T ICC Technician's Certification Number 5 ,?319- V T Expiration Date S 119)0,7 <br /> o <br /> R ICC Installer's Certification Number 92S'23 j` - V 1 Expiration Date V ?v p 7 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T Cf I G r.►d ()„Kew_ I vn K-10 w.. <br /> A <br /> N <br /> K <br /> P —Approved XApproved with conditions :Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name—IA laula Date Q <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 TO <br /> 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 /> Applicants Signature Title :C Q A i -- Date 1,; 3 AP& <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 <br /> �rthe <br /> .billing by signature and date below. G m <br /> NAME 040VA .�QO -. / G�:TTCE QyA V 4" TITLE SE(ZV,C/i�NA VPHONE# /�6 Q?6 (�J�.2,P <br /> ADDRESS47y2 SlifeR 4 Cover �D .��Lj_� J', OV61,1,V i9S�t,? <br /> SIGNATURE <br /> EH230038(revised 8/8j06) <br /> 1 <br />