Laserfiche WebLink
• • <br /> 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 ❑ PIPING REPAIR/RETROFIT ?�UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# p Project Contact&Telephone# ftg ar t!o;-? ?-- <br /> A <br /> Facility Name 1 TN Phone# <br /> L Address CL ve <br /> Cross Street <br /> T L <br /> Y Owner/Operator A �L S� P� Phone# Z— CYT <br /> CContractor Name -0 Phone# <br /> 0 <br /> N Contractor Address O&A apt Cjq CA Lic# 77& -93y Class <br /> AInsurer Work Comp# <br /> o <br /> r ICC Technician's Name Expiration Date <br /> R ICC Installer's Name p -{Zb 52$'Z - V/ Expiration Date I Z-0 U <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T OvG'� �.�11 fe gOrT N A' 9 <br /> A ox rfcVr <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A ach With Conditions) <br /> A / <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WOR/<N 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 F WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATIZLA _IF CALIFOR IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCORK F CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Date <br /> Coe 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 y signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS Z Vo-2 Ahft-4,0 //.4�(a� P-2�2 <br /> SIGNATURE DATE 2 0 <br /> EH230038(revised 02/20/09) <br /> 1 <br />