Laserfiche WebLink
0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <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 />Project Contact & Telephone #Tose P;,•,ecigMS' yZ3- 7 / 73 <br />A <br />D <br />Facility Namej ei-arenceL;Yerjqor4tN4t'ionelLa6raia - Srfe 300 <br />Phone # NZ -5 X23 - 96Z 6 <br />� <br />Address C orrej No// o w Road' T r(Lc GA 17S3 76 <br />Cross Street .Th to r,s' f qt a 500 <br />T <br />Y <br />Owner/Operator US. P.LpdwtMent Df FnerjX NNS <br />Phone (qZ5) yZ3-66Z6 <br />o <br />ContractorNameSupew.orUNder rouwd =rank •Serv;ees <br />Phone #(9ZS) 5S/- 7 88 7 <br />T <br />Contractor Address P p eoX ly$]` San gome„CAIVS83 <br />CALic# t{$Z3S(� Classy $ CZI C21 / <br />R <br />A <br />Insurer S ♦ Co <br />tae w�peNSa'�'iaN TNSUYaNGe FV NP� <br />Work Com p # 1 Yz o 36$ <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />0 <br />R <br />ICC Installer's Certification Number -r2-5y q,S7 - U I <br />Expiration Date j / • ! q - Z ol0 <br />Tank ID # <br />Ta;� Si a <br />4NONi <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />320c'"31115040 18 <br />IS 00o <br />asont•Vh1e4dQ� <br />-Tune 199y <br />A <br />N <br />K <br />P <br />❑Approved pproved with conditions []Disapproved <br />L <br />chment ith Conditions) <br />elllz <br />A <br />NPlan <br />�j <br />Reviewers Name ✓ 0 [at 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, ENVIRC ENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF T 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 COMPENSAT N LAWS IFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOR NCE OFTHE>GRKFORHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." ft <br />LA�L <br />9 <br />FII <br />Applicants Signa r4 Title eel - +C0'41 (Of SM4MA R✓ Date <br />W Jose_ r i n es4% t31LLING INFUKMA I IUN: <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 N A TITLE PHONE # <br />ADDRESS <br />SIGNATU <br />EH230038 (revised 12/31/07) <br />1 /,y <br />q <br />