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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 6AM 2691 4U 1-6A <br />O <br />Facility Namefcko <br />Phone # 9 <br />I <br />L <br />Address T <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator `i IS 6 w <br />Phone # <br />C <br />Contractor Name <br />Phone # 709 - <br />N <br />T <br />Contractor Address 2515 W Itiwnra Dh A Li c # ClassAfj <br />• <br />AInsurer <br />"5c i�{nr%"" _ ' ' Work Comp # <br />TICC <br />T <br />Technician's Tame Expiration Date ' <br />a <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system Work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Namemay„ __ Date_ 0� <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." • <br />n <br />Applicant's Signature_ �lv)___� TiUe_Date Gr1- <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 <br />signature and date below. Nrn w(T� n,/ <br />NAME ITV _ru Il JI f11QC�IVI�J . mV TITLE_ 65 AfRO�l6 PHONE � L_� 1 —_ <br />ADDRESSYLL1�.4YW�m q R • Old -4 OJR • 95'3/it - --- <br />SIGNATURE_ ti)kJL1 l) _ DATE_�_��___ <br />EH230038 (revised 02/20/09) <br />No <br />