Laserfiche WebLink
• <br />9 <br />ENVIRONMENTAL HEALTH DEPAP1V� <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 0 C T 24 2014 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANKRONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />�FacilityNameCPhone <br />Project Contact & Telephone # <br />A <br />Cl <br />�J l <br />L <br />Address( � c <br />fJ <br />UbT <br />TCross <br />Street <br />Y <br />Owner/Operator Phone # <br />C <br />'a"111 <br />Contractor Name Phone # <br />N <br />T <br />Contractor Address ( CA Lic # Class q /1 /� `� <br />R i'�t) tt� <br />RI <br />A <br />Insurer T Work Comp A ,,q <br />C <br />T <br />ICC Technician's Name Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />A <br />(S a Attachment With Conditions) <br />N <br />({� p� <br />Plan Reviewers Name -' n Q Q CXR Date 11 / <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 <br />CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF' CALIFORNIA:' <br />pp,, may,, tt� <br />Applicant's Signature Titlerlen(e5t11�11t�4n,.(� na i l �^ i- /`I• %�1 <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-�i�F.� nn �i Tt 5 CiC �0 hat W�}I� hw <br />� �" <br />h l / r.- -- TITLE`��}`\(�) PHONE GCJI �l�t��0, <br />ADDRESS tib? �LWiuom 160f, `1'141. Tun r J q 9Sf _ <br />SIGNATURE- DATE Q � <br />EH230038 (revised 08/1/11) <br />2 <br />