Laserfiche WebLink
5)34 'm <br /> k Y r .,r If YI+Y: ,Y <br /> `i W,' , ♦ Y Y y ` 1 ,.-+. .,w 'r It 1 tr r .'i <br /> r. <br /> S ' <br /> Y <br /> Iff <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 <br /> - - SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209)468-3420 rax: (209)468-3433 <br /> APPLICATION FOR UNDERGRdUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMITEXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PF.RMITTYPE BELOW: <br /> ElTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone.#._ 1 <br /> C Facility Name t U Phone <br /> I Address L <br /> L , <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# ! - � <br /> C Contractor Name <br /> Q Phone# <br /> T Contractor Address - CA Lic# <br /> n Insurer <br /> a Work Comp#LOPL5 <br /> c <br /> o ICC Technician's Name <br /> T Expiration Date <br /> ICC Installers Name <br /> R ' _ Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> em <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approvedpproved with conditions ❑ Disapproved <br /> A - (See Attachment With Conditions) <br /> N Plan Reviewers Namedz ,r�� Date <br /> APPLICANT MUST PERFORM ALL WfPkK 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 /> 0.F`CALIFORNIA." <br /> Applicant's Signature ��] Title P� ��V Date & t 2Q <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 L ITL ID C _ X GAS In hal)(Ilam_ <br /> hh ���1 _TITL _PHONE#� <br /> ADDRESS <br /> SIGNATURE _ ��- _ _ DATE_ <br /> EH230038(revised 08/1/11) <br />