Laserfiche WebLink
6 <br />ENVIRONMENTAL HEALTH DLtARTMENT <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT OLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name V <br />Phone # <br />IAddress <br />0 d L G I _ <br />TCross <br />Street <br />Y <br />Owner/Operator i ` jj <br />Phone # <br />c <br />Contractor Na ` 1 ® <br />' A14+1 <br />Phone # <br />o <br />� s say► 1C tc� I l� a <br />N <br />T <br />Contractor Address2G1Xc„lv ` �� <br />CA Lic # Class <br />:�S <br />A <br />Insurer S° <br />Work Comp # <br />T <br />ICC Technician's Name <br />Expiration Date - -� <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />87 81 leak detector, UDC 1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. piping sump, etc.) <br />T <br />7 % a, ` <br />Z-- <br />) <br />A <br />N <br />1;1- <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 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 CERTIFIES THE FOLLOWING: "I 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 PERFORMANC OF THE ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title Date <br />BILLING INFORMATION: <br />Indicate the responsible parry 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 />ENAMI �i� L� , 10 t"/fTITLE PHONE # <br />SIGNA <br />EH230038 (revis'e'd 10/30/12) <br />TE <br />