Laserfiche WebLink
a r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WE13ERAVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT_PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +-------------------------------------------------------------------------------------------------------------------------------+ <br /> ; EPA SITE # ;_PROJECT CONTACT & TELEPHONE # Joe Ba le - 20_ 367-4800 ' <br /> +---- ----------------------------------------- ------------------- -g---y-�--9 <br /> F ; FACILITY NAM <br /> --Cori).—Yard----------------------------- ; PHONE # <br /> A +------------- ------------------------------------803079----- -------------- <br /> C ; ADDRESS 1810 East Hazelton Ave. Stockton 95202_ _ _ <br /> I +------- ------ - - ----------------------------------------; <br /> L ; CROSS STREET <br /> T ; OWNER/OPERATOR PHONE # <br /> Y ° S._J._County Public Works_ Dan McCann,_Fleet_Manager�_____+_____468-3106--------------------- <br /> ;---+--- <br /> c ; coNTRAcToR NAMEBa le Enterprises, Inc , PHONE #367-4800 ' <br /> iD +-------------------g--y------- --------'-------'-------------------------------------------------------- ----------i <br /> N ; CONTRACTOR ADDRESS 2370M., - - CA LIC # CLAS <br /> i T ---------------------------J1•K_lgg .Q_�a- �__/�_4,_ 1i-_95-Z_4Q--`---------17A8Q2----------'-----%,-CfdkDW34.,. -P) <br /> R ; INSURER Monroe & Monroe : woRK.cOMP.41788625-2005 <br /> iA '---------- ---------------------------- - +- ---------- ---_"------------ <br /> C ; OTHER INFORMATION Gen. Liability 02 GL589707 <br /> O : ; PHONE It <br /> , <br /> ; PHONE # <br /> --------------------------------------------------------------------------------------------- <br /> TANK ID # <br /> TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOIISLY ; DATE UST INSTALLED <br /> 39- <br /> T ; 39- <br /> A ; 39- <br /> N ; 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> + ; ((( <br /> L- „ "„"," „"PROVEDYAPPROVED,WITH,CONDITZON(S ; DISAPPROVED ,,,,, <br /> A \ (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIBWSRS NAME <br /> +-^-„ ,,,,,,,,,„1,„ 1 „ �, .I.,,,t <br /> APPLICANT MUST PERFORM ALL WORK INA CS WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RL3GULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OP CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITL.EGeneral Manager DATE <br /> , <br /> +--------------------------------------------------------------------------------------------------- + <br /> BILLING INFORMATION: ''ec- ' *\C.)--�, o� <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone# <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />