COMPLIANCE INFO_2003-2007 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +---------------------------------------------------------- -------------------------------- ' I EPA SITE # ------------------------------- -- + --_--_-PROJECT-CONTACT-&-TELEPHONE-#-M(C9Q�L-//'AL�O�--9�p--3�3 +- ------ ------- _ALL F FACILITY NAME /� c� �-----------------' A ----------------------------------- U I V_ J TO PHONE # S`( 0- - O O I'--------- -- 6 r� gs ---------------------------------- C ; ADDRESS �, 2. a, -1- I +-----_lit/EST LQ._0------------ $T0CrC1-004 ------------AAAA-- - ----- --------- L ; CROSS STREET ' I+------------------------------------------------- ------------------------------------- ' T OWNER/OPERATOR Y t� U ( K S t-01, VA 4-2 IL F>I-T SA[ C PHONE # StAAAA---AAAA---AAAA------- 0 -6r4- Fro 0 ---+--------------------- ------- T---------+- ---------------------------AAAA-' C ; CONTRACTOR NAME ( ! /�-L I C--- �` ! RC �, C'J r 6 3 } 3 - l S' L S!" _-PHONE-#- _ O +AAAA----AAAA--AAAA-- ---�------AAAA---------AAAA-- --AAAA-AAAA--AAAA--AAAA----AAAA' N CONTRACTOR ADDRESS Q_Bq y �O Z r - �_-S �_rO, C A, gr6Q I_-CA_LIC -# /_� } Z 3 A, D L 1 4 Z T +----------------- - V J� .SQ I CLASS P FF - -- ------------------------qAAAA---J--------' R INSURER-----` .j. AFT E___ ery A WORK. COMP_#_ } 13 �_ l Z'_�_�_ l_ ' A 'AAAA- s2 t ------11-------------------------------------------------+- --- C OTHER INFORMATION ' T+------------------------------------------------------------------------------------+----------AAAAAAAA-AAAA-AAAA--AAAA-AAAA-' 0 PHONE # TANK ID # 39- T 39- A 39- N 39- K 39- 39- 39--__ 9- 39-39- _ L V A ; N PLAN REVIEWERS NAME PHONE # --------------------------------------------------------------------------' TANK SIZE ; CHEMICALS STORED CURRENTLY/ PREVIOUSLY ; DATE UST INSTALLED Mb-TIET PROVED WITH CONDITIONS) DISAPPROVED T E WITH CONDITIONS) DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI . APPLICANT'S SIGNATURE:TITLE C o �- 2 �O A, DATE $ 3 IO S I +-------------------------------------------------------------------------------AAAA-- —1-S -----------AAAA-- 1 -------+ 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. WA(.•rog Name , kc,Address .0 BoK tozr W- S;A-t," Phone#_q4 -3�-3 •114rz srda l Signature Wl Cif,4 A- &-C. E , W4 c T-6, { EH230038 �lr (revised 1/31/02)- ��