Laserfiche WebLink
SAN JOAQUIN COUNTY RECEIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 MAY 0 5 <br />2011 <br />aI * 0 0,. ; <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C,V40 -, <br />Af <br />Facility Name �e �,. <br />Phone # <br />I <br />L <br />Address (a t ® G <br />Cross Street <br />T <br />Y <br />Owner/Operator j Ct 0 V C <br />=- <br />Phone # — L <br />oContractor <br />Name <br />Phone #C <br />T <br />Contractor Address �® <br />CA Lic # .�l '' c+4 Class c ` (� <br />AInsurer <br />�"Co <br />Work Comp # Q <br />T <br />ICC Technician's Name C_ v-w1j <br />Expiration Date <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <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 Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT( 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." % <br />'� Date <br />Applicant's Signature CTitle <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 />NAME1-1 Wil, TITLECOWLaufe aRA&PHONE# C ` ® I <br />ADDRESS (�4' _- o lei _ q5 t t <br />SIGNATURE.sIAJa j__�- If DATEIr-- <br />EH230038 (revised 7-26-2016) 2 <br />M <br />