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 EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name 1'�A j 5E r(Z. � QM AiJ E'r,1T Phone#(2.0 <br /> � AVI(p G�© <br /> I Address ` , <br /> L �] WEST' �A•N E 'T�C.✓EGT©N <br /> I Cross Street AMMIS Q- ""S <br /> Phone# <br /> Y Owner/Operator E' p C°loq� "� 4r 3 <br /> c Contractor Name (q^F, �N�) �� Phone#(C1 160 S ISS- 421 <br /> CJ <br /> N Contractor Address Z-'7 O( I3�L PP.S O CA Lic# �� Class <br /> T <br /> R <br /> A Insurer Work Comp# <br /> T <br /> T ICC Technician's Certification Number Expiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T E)AO 2-4cllq 0 1 12-000 - >rESEL_. L- <br /> A Sg000 2-32- ©ZA <br /> K <br /> P ❑Approved 'Approved with conditions []Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date/`j <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 AGENT'S 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." Q <br /> Applicants Signature Title .Y�7 J\A Date 2- 15 1 <br /> BILLING INFORMATION: <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. GIS isF- <br /> NAME E' –t::) +T'?ilO G4 A —TITLE—G-WEaInr&V—= PHONE# 'Z09 <br /> ADDRESS EST' LAi.�� S-rcc arc) C.A <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />