Laserfiche WebLink
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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW- <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone <br /> A <br /> O Facility Name Phone# <br /> I Address <br /> L <br /> T I Cross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name Phone <br /> 0fC® <br /> N Contractor Address <br /> T JO A e"n. CA Lic# j0 Classy-a,4-0,#1t4Z. <br /> R <br /> A Insurer Ae-Wz,-je,.-jZ Work Comp 00,0Y 71,72,7-' <br /> G <br /> T ICC Technician's Name Expiration Date <br /> 0 <br /> R [CC Installer's Name Z-735(z- Expiration Date <br /> Tank system work area Date LIST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently Installed <br /> T AeZ J, <br /> A <br /> N 14W111 ZWi4 <br /> P El Approved Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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, 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 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." <br /> Applicants Signature Title---/ <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. <br /> NAME-67z,-:�- TITLE PHONE# 9/a/' e?-j <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 08/1/1V <br /> 2 <br />