COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"D FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT - - - ----------------- ----------+ ---------------------EPA SITE # ---------------------------'----------------------------------,'j�'J-�-{-�--�---------------------------------------- i -- - - -Y 1 - PROJECT CONTACT & TELEPHONE # --r+.'--=-=-'��y- `__1�.1_� (o-1 " I +SSSS'SITE----SSSS-- ------------------------ \.-`:-'a -�,Y SSSS---------------SSSS - - -- - - ------------------ ----- F I FACILITY NAM- .C � PHONE A --NAME-SSSS--- - -------------------------------------------- C ---- -#------------- 1 ------SSSS-SSSS-- -- C I ADDRESS I + ynn, �� ---� --SSSS-' L ; CROSS STREET ' I +--"--------------------SSSS---------------SSSS-------- . r -------------------------------P-------SSSS---SSSS---SSSS--SSSS-SSSS-- X_; OWNER/OPERATOR U-s- (� ` Pe�� _ ^ �( 1 5 � c -- 1 +-------------------SSSS-- +--- - --- - - -SSSS- ------------ ----SSSS-- ----------------------------SSSS-- --- -- -�� I C I CONTRACTOR NAME PHONE # 0 +-------------SSfir ,SSSS - - �s,�tY�- --------------`--- ISS-- - - N 1 CONTRACTOR ADDRESS ; CA LIC # CLAS T +--'SSSS--SSSS-- SSSS- :-- ``- -.Q i1----------------7_+------'��=SSSS-5 i�_ R ! 'INSURER ' WORK.COMP.# C _ - A --- -- +-------SSSS-- $u 5 -r�C3_ __a J..[) �_ -- ------------ --------------------------------------------- 1 C ; OTHER INFORMATION I 0 I ; PHONE # IR +--------------------------'---------------------------------------------------------+---------SSSS--------------------------' PHONE # {I'---------------------------------------------------------------------------------------------- TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A ; 39- I N I 39- K ; 39- 39- 39- _ +"-)iiiii ir,iiiiiiii i1i1i1i i,iii i.. ..........i ii i,i i,ii ,i iiiiiiiiiii I P L ; APPROVED11'r ,Ii'APP r „ITE DISAPPROVED!' A A I NS) N I PLAN REVIEWERS NAME S .3.- DATE OS APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY QA �GNATURE 8 ATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, Z SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE 4FV44 TITLE Q ffira,0 z`_-A \ ATE ; +---------------------------------------------------------------------------------------------------------------------------------+ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Oddress pf3. "PX �g`'�, Phone Signatureyix.,�_ s EH230038 �� _ (revised 1/31/02) ,, 1