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 /> l9J"TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# I Project Contact&Telephone# s Y S�01 f' CnS oL'Y6141 <br /> A Phone# <br /> O Facility Name �b S C ti <br /> I <br /> L Address &%U A j--nZ`l C. L-LfZ (6L - S-T G TLS A <br /> TCross Street <br /> Y Owner/Operator <br /> Phone# GjaG-( � -l4 O(p Z <br /> o Contractor Name C-6411L- PC--V 6, Q 1 Z-U f" Phone# �a�-4. of L <br /> T Contractor Address &f CA Lic# LM(ClLj Class e I- � <br /> A Insurer m t p C�f r11 (z�,/ l�(S (4 e.IJC-� Work Comp# 1L 5'�j(n ) <br /> c <br /> T ICC Technician's Name �kiJ EaLS M A Expiration Date g/1 y /f <br /> Q ICC Installer's Name JZ i(1't/ p L4 ' I I <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> F, ❑ Approved >kApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �C Z�/n <br /> APPLICANT MUST PERFORM ALL WORK I 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 <br /> TO 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 /> Applicant's Signature Title Date <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 pelow. <br /> NAME 4AEUl 1. U&I f'J �na'�'S 4_�'ALL/ TITLE Cy d PHONE <br /> ADDRESS p(o � I� C J� PLCA- J <br /> SIGNATURE `'"" �` DATE �( <br /> EH230038(revised 02/20/09) <br /> 1 <br />