Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT PING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name aj, Phone# <br /> I Address j iLoa <br /> r <br /> TCross Street <br /> Y Owner/Operator r�y.` (,t,� Q' Phone# �--' <br /> o Contractor Name ,,yam_ Phone# <br /> T Contractor Address rJ 0 CA Lic# q5? Sig V Class D <br /> R Insurer t�Yl�� � . Work Comp# �2/ ::W�, - 6 <br /> A <br /> T ICC Technician's Certification Number �& / 2 Expiration Date 6 0 g a l <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approvedpproved with conditions ❑Disapproved <br /> L (Se achment With Conditions) <br /> A TN Plan Reviewers NameDated_ <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 COMPENSAT ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR A OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ,�r �1 <br /> Applicants Signature Title %" Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to lied for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is dl ent than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility`for the billing by signature and date below. (qatv)NAME CIO f � 1;77 TITLE N�l C PHONE# { •��~��(� <br /> ADDRESS I / '— <br /> SIGNATURE <br /> EH230038(revised 8/8/06 <br /> 1 <br />