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 REPAIR/RETROFIT ADC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# C 0000 90 3 Project Contact&Telephone# e�,�D k (7 <br /> A / <br /> G Facility Name �, orl c Phone# 6-- t� <br /> Address L Fmak We,+ (SAdAun <br /> T Cross Street <br /> Val Der [11f) <br /> Y Owner/Operator ��r Phone# - 7 b <br /> o Contractor Name _ Rv(krlPhone# qI 3 O <br /> T Contractor Address Ctt 0 DrtUe ' ') CA Lic# Class 4 Ra Z <br /> R Insurer Work Com # ^� '�JC <br /> A -�"�'� p 235-���spy g <br /> T ICC Technician's Certification Number _ Expiration Date g_ -C <br /> R ICC Installer's Certification Number Z 3I Lj -L1 Expiration Date _ _b <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> TC L L <br /> A r `�� CID <br /> N 14 A7 <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L Se�Aachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date b <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 ORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature - Title :�?tU C EnI VA Date ( 1-0 toe <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 P�'e�. G,C- a t,� TITLE -VI-0 k(- Rq I/I,PPr PHONE# <br /> ADDRESS 99 C-4Pr tt ud Po l sb t �>,crc, CA oc)4 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />