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