COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMITEXPIRES90 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 +---------------------------------------------------------------------------------------------------------------------------------+ I i EPA SITE # I PROJEYT CONTACT K TELEPHONE # CR �`�------------------------------------------------- - -n� w�r�1s- --55 =55_��5� I +------------ 1 F I FACILITY NAME -U G - �f- I �� #----------- -----_ ----J 1 C 1 ADDRESS ( I, 1 _\ 1 /1 I 1 L I CROSS STREETI Le `IQ II +--- ------------- --- - -- -------------------------------------------------------------------------------------------I T I C)WNER/OPERATOR I PHONE # `db� I Y 1 -• ---------------- �ot�1---- ---= ----- a I C I CONTRACTOR NAME x'15 uL 1 DI 1 PHONE # I 1 0 +------------ - - - --- - - ------------------I - - - - -------------------------------------- - ------------------------------------------- I N I CONTRACTOR ADDRESS' ^1 G� �'. �"e n e. i COQ J I CA LIC # '�'Z Q`"')`' I CLASS Z 1 __-__ R IN ��-`� I WORK.COMP.# 5 llaa -a•e)l73 I A I--- --=--- �'�? Y�S�Lrpi n�2 SSU�-,-�rt --------+---------- - 1----------- ------------- I C I OTHER INFORMATION I I ______________________________________1 1 0 1 1 PHONE # 1 +----------------------------------------I I I I PHONE # I +---Illlllllllflfllllllllllllllllltl------------------------------------------------------------------------ ------------------ __I 1 1 TANK ID # 1 T �nC SIZE_ I I sTo CURRENTLY/PREVIOUSLY 1 DATE U ^IiSTAI1.ED I 139- I 1 Ogg I 7 I / 'f I T 1 39- I c I I 11 / I A l 39- I { I I 1N139- I I I I K 1 39- I I I I I 139- I I I I I 139- P I I I I +---{III{{{IIiIIIIIIIIIIIII{IIIIIIIIIIIIIIIIIIIIIIIIIIIII{{1111{II{{III{{Illlllllllllltlllllllllllllllllllllllll{{Illllllltl II IIII I L I APPROVED APPIK)VBD WITH CONDITION(u DISAPPROVED I A I ATTACHM@7T WITH CONDITIONS) `` 1 N 1 PLAN REVIEWERS NAME DATE ` +---{{I{IIIIIIIIIIIIIII 111111 II II III IIIIIIIIIII{1111111{{{IIIIIIIIII11111111111111111 1111 IIIIIIIIIIIIIII{IIIII I I 1 APPLICANT MUST PERFORM ALL WORK IN SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND ROLES AND REGULATIONS OF 1 1 SAN JOAQUIN COUNTY, BNVIRONME?NTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY I I 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 I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALE.EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I 1 1 � I ` 1 APPLICANT'S SIGNA TITLE DATE [� 07 J 7 I I1 +------- - ------------------------------------------------------------------------------------------- ---------------------------- 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_Qth C°-_Address 30)01 oU�o� ',#a-()�—_Phone CIS-hl59a00 i clli�