Laserfiche WebLink
vIRONME'RTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,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 go DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT <br /> ❑UDC REPAIR/RETROFIT <br /> F EPA Site# F-f\ c-f-c -L '"� Project Contact&Telephone# r <br /> A t-- �1 to t — <br /> C Facility Name LV <br /> C- �, �- Phone-0r <br /> L Address <br /> TCross Street <br /> Y Owner/Operator �_� r <br /> G C� t.j Phone# z i <br /> O Contractor Name Ncl Phone# <br /> N Contractor Address <br /> T CA Lic# 1.20560 Class C <br /> RInsurer <br /> A c'` U� Work Comp# ()(� 7 f7'—© <br /> G ICC Technician's Certification Number <br /> RT _Z 7 —� Expiration Date C�� 2� <br /> ICC Installer's Certification Number 5 — u Expiration Date >— � <br /> Tank ID# Tank Size Chemicals Stored <br /> Currently/Previously Date UST Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name Q <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE IFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> CERT <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 LI THE IA." MANGE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �� //�� � <br /> Applicants Signature et�CTifle f'l.�- u�wl(� �?✓ <br /> Date__ <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 party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8106) <br /> 1 <br />