Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, 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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT L�PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> G Facility Name Phone# <br /> Address <br /> ICross Street <br /> T Jw <br /> Y Owner/Operator li-rLi Phone# <br /> 0 Contractor Name <br /> o Phone# <br /> s�✓Lv`Ll��. S I"T S M,S —hL• <br /> T Contractor Address — CA Lic# Class (� / 4O IML <br /> R InsurerLL) ,' _ Work Comp# 3 C» <br /> A 2 ✓ 1 r �Z� ( v' Ub SOL <br /> T ICC Technician's Certification Number Expiration Date <br /> T SJS �lS(�U - U p (o���v� <br /> ° nstaer's Certification Number umber <br /> R ICC IllC113 376 Expiration Date -4hJ <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved L�t"Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A "S <br /> N Plan Reviewers Name i Date <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 Date J <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 the billing by signature and date belo�.J�- S-e ro <br /> NAME a:ff TITLE (&S ? L�d= [ PHONE# -4Uk- 7l l 3 <br /> ADDRESS P <br /> SIGNATURE---q(_:) Q <br /> EH230038(revised 12/31/07) <br /> 1 <br />