Laserfiche WebLink
0 <br />• <br />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 />❑ Ib <br />❑TANK RETROFIT <br />PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # i pyl A.&t Vjk C-rct-( 9/ 6 - 3 it <br />A <br />O <br />Facility Name Q tJ I k S70 P 4-! <br />z o <br />Phone # <br />I <br />L <br />Address 93L t T1--oruLTe.4 <br />RD. Sroce T -o-►.{ 9 Szo 4 <br />T <br />Cross Street p, ( lit <br />a 14_1 5 2D <br />Y <br />Owner/Operator G v 116 ST --p to <br />W A -IL IL tis C - <br />Phone # 5-1C - b S} - 6'0 0 <br />C <br />o <br />Contractor Name I t4 E fZ c 4 r Y4 C_ <br />WAc.Tt� Fit: � <br />Phone # 916-343 <br />N <br />Contractor Address T3 p X i C Z s' <br />IA) . S Aa �o S 6 a( <br />CA Lic # 14 2-38- Class A, S. g prZ <br />A <br />Insurer ST k's -ll Fv <br />Work Comp# t3 - �i92 - ZOmf <br />TICC <br />Technician's Certification Number <br />5 EE A -C4 VN) <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />`� " <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />IN <br />N <br />A-..<0 L I LC-A_U <br />xl fL <br />K <br />P <br />❑Approved <br />_N�hpproved with conditions []Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Nam <br />% <br />Date <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />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." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF HE WORK FOR WH/CH <br />THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature <br />Title C 0 µ'T R Date 1 <br />V 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 />responsibilityforthe billing by signature and date below. <br />NAME U y` tG���- W L��� TITLE CGI*"��L flrL- —PHONE # 1,460—= V6-3:0 IIS'Z <br />ADDRESS �� /` i O Z a) . S A-e� C A gi - 6 q( <br />SIGNATUR <br />EH230038 (revised 12/3 <br />1 <br />