COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R0 FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROMT APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: --TANK RETROFIT PIPING REPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------- -------------------------------------------------------------------------------------------------------+ EPA SITE # i PROTECT CONTACT &TELEPHONE # _____________________________________________________________________I F I FACILITY NAME l ��1�.J/`..(y�]�'' I PHONE # A +-------------------�` -----1_--T ----------------------------------------I----------------------------—---------I I ^ r C I ADDRESS X_-- / •'-LCA �.�'�ex�_p t- I J -- '- - - ----------- ---------------i L I CROSS STREET I +------------------------------------------------------------------------------------'----------------------------------------i T I OWNER/OPERATOR I PHONE # I Y I C I CONTRACTOR NAME f `(�/ e..� O +___--- --"------ 1_�'----"O'- -----------------------------------------------------PHONEIY✓ ------ N I CONTRACTOR ADDRESS '2S'7 • ( i CA LIC # i CLASS L• - ---- -- -- --------'-- T +---------------------------- -- ----------- I R I INSURER 4 1_r�s WORK.COMP.# 1 I I r_ -v•_ I I � I C I OTHER INFORMATION i ---------------------------+__--_----------------------------------' O i PHONE # I I I PHONE # 1 IIIIIIIIIIIIIIIIII111111111111�------'--------'-----------------------------"------------------'-----`------'-----`---I 111111 �� 1111111111111111 � I TApN�K ID # I TANK SIZE I ICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED i - I 39- -7 I 1 1�� E U P I I I T i 39- I I 1 I I � A I 39- i i 1 N I 39- I I 1 I I I K I 39- 39-_ 9-39- � 39- +_--IIIIIII IIII��III111111111111111111111111111111111111 IIIIIIIIIIIIIIII IIIII IIIIIIIIIIIIIIIIIIII1111111111111111111111111111111 1111111 ILII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIII��IIIIII III IIII�11111 IIIIIIII�11111111111111111111111111111111111 P � L I APPROVED APPROVED WITH CONDITIONS) DISAPPROVED 1 A I l ^n On,Fs�E#�ACH�WITH CONDITIONS) Q N PLAN REVIEWERS NAME A/ 1 1 DATE +__-I I11111111��1111111111 1111111 I 1111111111 1111111111111111111111111111111111111111 1111111 11111111111111111 1111111 IIIIIIIII IIIIIIIIIIIII11111111 1111111111111111111111 I111111111111111111111111111111111111111111111111 IIIII IIII11111111 I 1 I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY i i 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 I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I I I APPLICANT'S SIGNATURE: TITLE DATE � I +--------------------------------------------------------------------------------------------------------------------------------+ BILLING INFORMATION: Indicate the responsible 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 party must acknowledge this responsibility for the billing by signature and date below. Name _��______Address_ �_ _ __Phone