COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +------------ ----------------------------------------------------------------------------------------------+----- EPA SITE # I PROJECT CONTACT 6 TELEPHONE # - ------ - - - - - F , FACILITY NAME D p}, PHONE # ______________ C ; ADDRESS 1Cl 0 �0 N . E �� q �, L I CROSS STREET I +_______________________________________________________________________________________________________________________-I_____ T OWW`NER//OPE,R(A'TOCR /� r P/H�ONE�C# Y V? W C J , �' �1, �!�J p li C. l,. ` 1 1 A. (,70 __-+_____________________`___-_____________________.j_______________________________ _____________________________1_ C , CONTRACTOR NAME S J ( A A i (� (�.` PHONE # --C:U U 59 , o +--------------------------------------------------------- N CONTRACTOR ADDRESS) ' f' /�� n�r ` 1\ t /j, CA LIC # y 1 "� CLASS L.� �1 T +-------- �-jj- -------(-�y- ---IJ--Y-'- -f-1 ---- -------i-,--- r-llt---------------- --1-------------�-,-t-1--31-[,----`----- R INSURER \f AT C WORK.COMP.#4% 7 r,uv�ASI_b3 --1 ,__________JJ________L___ ---------------------------------- C l- - -1 C ; OTHER INFORMATION , T +_______________________________________________________________________________ ------------------------------------ 0 ____________ -_________-_-_o I , PHONE # R + ______________________________ ________-_________________________i_ PHONE # ____________________________________________________________________ _______ 1f1 'fTANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39- 39- 39- ............ 9- 39- 39- P L APPROVE APPROVED WITH CONDITION(S) DISAPPROVED / A (SEE ATTACHMENT WITH CONDITIONS) ��I Q N PLAN REVIEWERS NAME o(yy� DATE APPLICANT PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS qF SAN JO IN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERT4FYTHAT IN THE PERFO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY AMSGN IN SUCH A MANNER AS TO B OME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE OLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT;T© WORKER'S MPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: -./ TITLE A DATE 6,' /Q5 t}9 +--------------------------------------------------------------------------------------------------------------------------+----- BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Phone# T��er�7 .t.� A�0<e''v1t� °rre'�c/ u,.�.��e �2 �,Y�S�i.� �••./r�/srd J�r�e� oo-r �Z.� p!C v�oNJ 6�� j¢�ww��.fR vo 35'-�L . (See ��'Cuw'�s �rru,��iq/B�'�ov-�/ ec�ao�-�•�•�'�a..✓eo..al��,.�..i. 0 Com��aL�or is �o Cca�� a cod c�' �leJli+tS fer7wcA cJ �K,.