COMPLIANCE INFO_2007-2012 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, Third Floor, Stockton, California 95202 Telephone: (209) 4683420 Fax: (209) 468-3433 THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT F EPA Site # Project Contact & Telephone # A C Facility Name OZ G Phone # L Address TCross Street Y Owner/Operator Phone # C Contractor Nam Phone # �J 0 T Contractor Address// --"007' CA Lic # ® Class A Insurer Work Comp # TICC Technician's Certification Number LIZExpiration Date r� J R ICC Installers Certification Number , Expiration Date Tank ID # Tank Size Chemicals Stored Currently/Previously Date UST Installed T / �- A N K P ❑Approved pproved with conditions ❑Disapproved KAachment L (See With Conditions) A N _ Plan L Date �� Reviewers Name APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THY WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Applicants Signature �A Titte�ififil(!�/rid Date BILLING INFORMATION: Indicate theresponsible 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 parry must acknowledge this responsibility for thebillingby signature and date below. NAME0i�!�ii�1/ /�/ �� TITLE PHONE # (revised 8/8/06)