COMPLIANCE INFO_1997-2006 - 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 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: ___TANK RETROFIT Y__'P*H MREPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------/-----c-- ----------------------- ------------------------------+ EPA SITE # PROJECT CONTACT --- TELEPHONE -# �/ !/ U b�l�%//,ray/ _/�/ _ 1 F 1 FACILITY NAME//� /tf C 1 PHONE # 1 C i ADDRESS_ ----------------------------1 L 1 CROSS STREET / 1 I+____________________ ___V___________________________________________________________________________________________T OWNER/OPERATOR ec,LCLC/- - PHONE # 1 1 Y +- �) 'K ,HL(ZG3'S�ccTI(X_ i------SZ�7Q?------+-------------------------- - - 1 ^ /f ---------------- G 1 C CONTRACTOR NAME __ \ A v ____! RA J'�v '___ _________PHONE #/S�D� 1 N 1 CONTRACTOR ADDRESS [J ()( �� ' l A - -- CA LIC # , S Qy x 1 CLASS A e 1 T -----------------------_—` _____________________________ _______________-______________ a 1 R 1 INSURER 1 lU t y A OLJ' 4 s, Eerwe-A-s WORK. COMP. # 1j V 2 -ODOO Z 7 3__ Ai-------------------------------- -------------------------------------------------+-------------- ----------------- I C I OTHER INFORMATION I 1 IT+____________________________________________________________________________________+________________________________________1 1 0 1 1 PHONE If 1 R+____________________________________________________________________________________+________________________________________1 1 PHONE # 1 ______________________________________________________________________________________________I TANK ID # I TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 39- I i iN�VU i I ( T 1 39- i� (!� 1 A 1 39-1 N 1 39- K 1 39- 39- 39- + 1111111111111111111111111111111111111111111111.11111111111111.111111111111111 ---1111111111111111111111111111 1 11111111111 iii 1 11111 1 111111 1111111111111111111 11 1111111111111 iii i 111111111111111111111 P �p 1 L 1 _ APFR APPROVED WITH CONDITIONS) _ DISAPPROVEDA 1 /'�/^^�'TTA_CHMENT WITH CONDITIONS) N 1 PLAN REVIEWERS NAME v (/ DATE t� 1 +---III!III HIM! HIM 1111111111111111111111111111111111111111111111111111111111111MIM, 111111111111 1111111111111111111111111 I 1 I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 COMPENSATION LAWS OF CALIFORNIA." I 1 APPLICANT'S SIGNATURE: C� �---- TITLE 1 --------------- BILLING INFORMATION: THAT IN THE WORKER'S 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 --- Address ___Phone #.