Laserfiche WebLink
-1 / <br />,ENVIRONMENTAL 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. I <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT I It]Dr RFPAIR/RFTR(1FIT <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # <br />NN <br />C <br />Facility Name d <br />Phone _ <br />L <br />Address J , v <br />TCross <br />Street <br />Y <br />_ <br />Owner/Operator U \ Phone #- <br />6S -1L <br />C <br />Contractor Name r �; ' <br />Phone # <br />T <br />Contractor Address 1 STt�lC9•Yl <br />CA Lic # ( an Class Ab L -16t <br />R <br />A <br />Insurer <br />Work Comp # l _0 <br />TICC <br />Technician's Certification Number <br />Expiration xpiration Date <br />o <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />L <br />N <br />❑ApprovedAproved with conditions []Disapproved <br />(See Attachment With Conditions) <br />Plan Reviewers Name Date '��✓II <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 AGENTS 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 FERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />�h <br />Applicants Signature j \ �Yk& Date �� t� 1 ✓� 1 <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 below. <br />NAME TITLE HONE # 269. !!N1L� <br />ADDRrSS 1 1ij1 MlJf�a\t ��]i5JS1L l�) _Cp ` r-, )� / <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />