Laserfiche WebLink
A <br />• 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />__jZKNK RETROFIT ____PIPING REPAIRIRETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+--------------------------- --------------- ----------- + <br />EPA SITE # i PROJECT CONTACT & TELEPHONE # <br />+____________________________________________________________________________________-____-__________________________i <br />F FACILITY NAME 1 PHONE # <br />A+________________I-\__u__-i-___c_---__���t 1 N` ______________________________________________________, <br />C ADDRESS kA <br />ELL � ��_-" .21..1 v--- -`=-i �L-.��--!zon-0----------------------------� <br />------ - <br />I +CROSS STREET___ ________ <br />_________________________________________________ <br />T OWNER/OPERATOR j� r{ ( n �_ �� -� PHONE # ) ` ___ <br />--------------------------------------------------------------------------------------------------------------------------------- <br />C I CONTRACTOR NAME �� .-- i PHONE # j <br />t� �G--------I-----------------� �`�-�---------------------------- ���5 -J� (--155_ <br />N CONTRACTOR ADDRESS/� `� ` f.� f /� /' I� <br />CAL-LASS <br />(�� - [---,J1-+�IL-'� li(�- �C t- �•b%.j- In1------- _-I--`------I----'--------- <br />/^F'�ry ' L Q� WORK.COMP.# <br />R INSURE 1. '. 1,1 \� �^-�JyI� L _ ---- /_________i <br />C OTHER INFORMATION <br />T+___________________.(1�_�;_�LP�I�-f__� _Cwt^q+tYa__-1-`____________________�� <br />O i PHONE # <br />iR+____________________________________________________________________________________+________-_______________________________ii <br />PHONE # <br />---' --'""-------------------------------"'---------' <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE USST' `INSTALLED <br />39- <br />T j 39- U yi <br />A 39- in ��C-70 AA57� <br />N 39-7 <br />K 39 <br />39- <br />39- <br />+ ii11 M I liliiiiiiiiiii M iiiiliiIMiililli M111111111111 1'iii'I....111111111111111111111111111111111111i111111111111111;1 i <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />i <br />i <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF j <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO i <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />COMPENSATION LAWS OF CALIFORNIA." <br />Zv7/,A ��J <br />APPLICANT'S SIGNATURE: TITLE / DATE � �j J <br />-------------------------------------------------------------------------------------------------------- ----- -------------- <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name —Address <br />1 <br />Phone # <br />