Laserfiche WebLink
! 1 1 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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: PI <br />TANK RETROFIT IPIPM-A RFPAIR/RFTPn;:1T 561 Me, ocn. — -r -- F� <br />A <br />EPA Site # <br />Project Contact & Telephone <br />C <br />Facility Name `l� <br />Phone # 540 -le571 - $Sbo <br />�Address <br />llJ30 ��.re, `INQexwC-- <br />TCross <br />Street <br />Y <br />Owner/Operator (� -� <br />Phone # <br />C <br />Contractor NameW Y-1 <br />Phone # 3"T5- `U -p <br />T <br />R <br />Contractor Address d p <br />CA Lic # (0 9 6 Class \AZ <br />A <br />cICC <br />Insurer <br />�,q �rn <br />Work Comp # `( k 600049 oil- 0.1 <br />T <br />O <br />Technician's Certification Number 5 aq _Expiration <br />Date <br />1 c� <br />R <br />ICC Installers Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />arc <br />1 <br />N <br />o1 <br />t11� <br />K <br />P <br />DApproved 1-*�Szpproved with conditions ❑Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WdRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I <br />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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS <br />OF CALIFORNIA" /��_J o <br />a <br />Applicants Signature. J1�-!i^ i�_�( ��p Title Qj=rVU\t0.V-1 Q- Date —1 -.Ab- OR <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. if <br />the parry designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsi Ility for the billing by signature and date below. <br />NAME_ TITLE PHONE # '\(, - 3-73 - k\ to <br />` ` <br />ADDRESS �. .�C7�C \Oai W - SP.C\V0 CA CL <br />SIGNATURE <br />p <br />EH230038 (revised 12/31/0 <br />1 -- <br />