Laserfiche WebLink
• 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 />KTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # JeV6 ,2I) <br />_36 7, eo-0 <br />A <br />G <br />Facility Name ��'i f✓��-�N�/,� �� !�/�,f%i <br />Phone #��? <br />� <br />Address <br />TCross <br />Street ; <br />Y <br />Owner/Operator C,V;el <br />Phone # <br />o <br />Contractor Name ��r%iE�i��'jJC/ /„/G <br />Phone # <br />N <br />Contractor Address ���p /�„6e���' v�Cc'l= `/�, r !f <br />CA Lic # <br />RInsurer <br />A <br />r�, <br />%lt7i,/.L'caE f1�.,/,�cn� �Cir/CRrs<. .�ii�,c�icT. / <br />Work Com # , <br />p fie, �/►>/GY� /�jC�/' <br />T <br />ICC Technician's Name Epp/ � Z/ <br />Expiration Date <br />R <br />ICC Installer's Name 201 UIJ9 -4d <br />Expiration Date N7&ZJ� gol C, <br />Tank system work area <br />(i.e. 87 piping sump, 91 leek detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />% <br />%? ®®O f;14/. <br />�� L1eJ�C� C <br />T <br />, <br />,� i�✓C� <br />A <br />47047 <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />N <br />(Se Attachment With Conditions) <br />Plan Reviewers Name � � Date ���— C: <br />_� _ 12 <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 AGENTS 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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signatur Title Date 0-4h Z <br />tiILLINU INhUKMA 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. 1 <br />NAME O jjtet y TITLE 1W 51 n FA!� PHONEUO rp` ) 267" `T�D <br />ADDRESS 2-370 M4-&&10 <�'l A CLC he /—a ®, CAS . q x-�A- aF 0 <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />