Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN <br />Ott I Iti t 95202 <br />Telephone: t 468-3420 ' i 468-3433 i. i r <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 C❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />FEPA Site <br />A Project Contact & Telephone <br />C <br />Facility Name Q Phone # �' — <br />1 Address ZC t. <br />L Lam, CSC f—C �s 1 <br />Cross Street f K1�.� ( �0 <br />Y Owner/Operator - _ <br />C <br />C?� �- - Phone # <br />C Contractor Name ' J <br />N � `IYt _ v i C�' i1 P. Phone # S <br />T Contractor Address r P-`� �— CA t_ic # <br />' ( Class <br />R � <br />A insurer C— En ri I rcy\, <br />C ICC Technician's Name Work Camp <br />T ' C, <br />R ICC installer'sName <br />IA U, xpiration Mat—'J <br />ez piration Date 6c <br />Tank system work area <br />0-8. 87 piping sump, 91 Ieak d®tsctor, UDC 1,2, e, Tank Size Chemicals Stored Currently Date UST <br />T <br />Installed <br />A <br />N <br />K <br />P ! Approved <br />L pproved with conditions <br />A Disapproved <br />(See A achment With Conditions) <br />N Plan Reviewers Name ' <br />Date 5 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY QRDINANCES, 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 THE 711,A7 <br />CE OF THE WORK FOR WHICH THIS PERM IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA."IIiA:' f <br />Apolicanrs ct.,�s«,s - 1" ,�, !' ," . /I f _ P <br />BILLING INFORMATION: mace {� <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />the party Signated below is different than the <br />respon ility the bill' g ignature an date be permit applicant' e.g. pro 9 p tank. If <br />/,/y_ji (j]�' ® petty owner, the party must acknowledge this <br />MARA- <br />SIGNATURE <br />E11230038 (revised 02/20/09) <br />11 <br />