Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />RECEIVED SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Callfomia 95205 RECEIVED <br />DEC, 16 202 Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />ENVIRONMENTAL APPUCATION FOR UNDERGROUND STORAGE TANK 16 2013 <br />HEALTH DEPAMMENT RETROFIT OR PIPING REPAIR PERMIT Wnf <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT <br />0 TANK RETROFIT 0 PIPING REPAIRIRETROPIT 0 UDC REPAIR/RETROFIT <br />UPGRADE <br />MI . 0 <br />MW 40 <br />Tank system work area <br />(1-0- 87PIPWV SMA 91 leak date=, UDC 11?, etc,) <br />11111111111111111[a <br />61 <br />A <br />Tank Size <br />T--e- <br />0 - I <br />..ME <br />Expiration Date <br />Expiration Date <br />Chemicals Stored Currently III man <br />P El Approved <br />L NwrO'ved with conditions El Disapproved <br />A (See Attachment With Conditions) <br />N Plan Reviewers Name— Date <br />iQUIN ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />COUNTY, <br />I'ENV ENVIRONMENTAL <br />HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />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 />RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />kT IN THE PERFOIR17MANC%�'OF THE RK FOR WHICH THIS PERMIT IS ISSUED, NS SUBJECT WO <br />CALIFORNIA I SHALL EMPLOY PERSO U CT TO RKER'S COMPENSATION LAWS <br />UC r3 Sign <br />ants Signa <br />i 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 Wow. <br />NAM1E)(!!6i[ 14 LL3±1kALL----3ITLE PHONE# <br />EH230038 (re vL4d J0t30112) <br />K <br />T <br />