Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave- Stockton, California 95205 <br />4 2 0 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />VN <br />4 <br />APPLICATION FOR UNDERGROUND STORAGE TANK-, <br />RETROFIT OR PIPING REPAIR PERMIT <br />TANK RETROFITHIS PERM! i EXPIRES 1,80 DAYS FROM THE APPROVAL DAIE NO)CATE PERM,�, �ypF BE <br />PIPING REPAIRIRETROFIT UDC REPAIR/ i JI, <br />F i EPA Site# <br />DE <br />A ProleCt Contact & Telephone <br />(, ; Facility Nam <br />Phone# <br />Address <br />'rn, <br />, q qt, - <br />Owner/operato,r <br />Contractor Name I` Pnone 9 <br />Contractor Address j:y Phone# <br />lit <br />A Insurer pytj CA Lic # <br />ICC Technicians Name <br />Work Comp <br />R I ICC Installer E)(piraYo <br />-me <br />Tank System work area Exp <br />Tank Size <br />C>em)cais Store <br />A <br />N <br />K <br />P <br />Approved <br />A <br />N <br />Approved with can <br />-See AttacnrnPnt VVItr) C;o, <br />,APPLICANT MUST PERFORM AL, <br />jOAQUIN CCjN7Y <br />'rHE PFRFORMANC ENVI RO, N M E H <br />OP <br />E , , , E " a E1: <br />OF 1HE NORK F'­Ik W-j�:, WORKER'S COMPENSATION LAVVI ERM'. <br />iN TmE PERFORMANCE OF 4'� 1RNIA C')N7r1A,',', 7 <br />;OF CALIFORNIA i HE &ORPI, F (--)LI VV"IC^l TmfS pER'M', I s <br />APPI?Cant s S;an.t, <br />indicate the responsloie party to be 011lea for add tonai ' BILLING <br />I iiEHD st <br />the Party designated below is different than tne Permit apt, <br />responsibility for the Wling by Signature and date bei ow <br />am <br />maxim <br />Rzms� <br />4 <br />,�t i , <br />_Lh7 - <br />Class (_ It',j � if/ /I , <br />CUPrentiy Date UST <br />Instaliecl <br />--- ------- I-- 1--l-l-, <br />ons Disapproved <br />ons; <br />N= <br />h. 'N'TRF CFRT��INL, RE&UE[iLATiONS Ow 'SAN <br />-�HE �YAlf`,G CERTiFy ?,HTTP <br />M4NNE _0 13PCOME SuS,Er, <br />P t �ILLOVVING t RT <br />C,F I <br />7(-, AjOR H <br />'(FR�S C(_)MPENSA-J()N­ <br />FORMATION <br />ex Pe nuecll beyond perrnj-, <br />InProperty ownert Dayment coverage per tank If <br />'r'e Darty rnuST aCKnowieage this <br />P110NF a <br />