Laserfiche WebLink
• <br />• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3410 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL OATS. INDICATE PERMIT TYPE BELOW <br />TANK RETROFIT UPIPING REPAGlIRETROFIT I h U)r RPPA <br />F <br />A <br />I EPA Site # <br />Pmjec:tContact & Telephone # ( `I i t 2 � ^fi - <br />C <br />L . <br />Facility Name <br />Phone# `"`� c'> ".3 i�"'fJ13 <br />I <br />L <br />Address " '3 rn <br />7 <br />�'-'r e <br />-i,il' <br />'iWW r,L <br />I <br />T <br />Cross Street <br />Y <br />OwnerlOperator C <br />�� i' l Cti U o <br />Phone # 3cl s-3 <br />C <br />o <br />Contractor Name * ' L,L <br />V <br />Phone #��i ^ j - is 33,. <br />N <br />T <br />Contractor Address �' r" <br />CA Uc # Class <br />xv� C C C c <br />A <br />Insurer `'r `, <br />.. <br />4 Work Comp # ice` ���'�C`✓ 1 '1�` <br />T <br />IGC Technician's Certification Number <br />Expiration Dais -7 <br />R <br />ICC InstaWs Certification Number <br />Fxliration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Cunently/Previously <br />Dom; UST Installed <br />T <br />A <br />M <br />K <br />P <br />L[ApPm <br />proved vim conditions <br />�P UDisapproved <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name 9AA444 <br />� � <br />�' VGL.Giit� Dam <br />APPLICANT MLISr PERFMM ALL MIORK MLACCORDANCE-IlIRWSAN J MtX UNTY. S:.STATEIJIV4& AbUgULE,S AIsD_RE%�.OF SAN <br />JOAQUIN GdtR Y, ENVff201 @AEMTgt 161.11 :7EPARTMENT. OV1R IER OR L C84SM AGENTS SIGl+IATU 2E CERTIFIES THE FOLLOMOG- 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR VVHiICN THIS PERwr IS ssUEp, t %W NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S CATION LANES OF CALUIC WD CONTRACTOR'S H IRWOR SIJBOONTRAMIW, SMATURE U=RIU-IES THE fOLLOVVWG: 'I CERTIFY <br />THAT IN THE PERFORlJ1ANCE OF THE VWCRK FOR VVHICEI THIS PERMIT IS ISSN, 1 SHALL EMPLOY PERSONS su&ECr TO vAxw zs COMPENSATION LAWS <br />OF CALIFORNIA' r-'1 , <br />SIWNG INFORMATION: <br />Indicate the responsible party to be billed for additional END staff time expended beyond permit payment coverage per tank If <br />the party designated below is Merent than the permit applicant, e.g. property owner, the party must adarow3edge this <br />responsih8iw fn, rr the bitlina by sianatture and below. <br />NAME�b bee � �ir C�/1 1 f-LCJ ,7i TITLE NONE #--X)9 - <br />EH23DO38 (nevLwd MM) <br />L <br />