Laserfiche WebLink
12/01!2008 XON 10r51 PAZ 209 3433 SJC 8114 -+--w Service Stat Sys- &Y 19004/005 <br /> NVIRVON MENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,CRIlfornla 95202 <br /> Telephone: (209)468-3420 Fax;(209)469-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERW EXPIRES 160 DAY&FROM THE APPROVAL DATE. INDICATE PERMO TYPEBELOW. <br /> II�� <br /> 2TANK RETROFIT NG REPAIRIRETROE:IT E6C RSPAWIRETROFIT 7-1=0 <br /> ; DSTASIT&NR UPGRADE <br /> F EPA Site IdProtect Contact a Telephone# , <br /> A ..�. <br /> G �ISV�� <br /> C Neltm <br /> y Phone .,>f av—Cl C <br /> .1, <br /> T <br /> v r stor <br /> C Contractor NameC4'� Phone t'1 r . <br /> T Contractor Address (0"$V ° 7 CA Lic# (F i l I t ' CI86b <br /> A lrleuter `f. CQ '�v` v v a: -c. fit}u.l. Work Comp 4 g 3k n 6' (Pb`E <br /> oIEC Technician°s Certification NLlmber Expiration pate 3 d 3 <br /> R ICC InstaAer's Certification Number E)*Ikilon Date <br /> 'tank In 6 Ta,*Ske Chelnials Stored pets UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> va <br /> K <br /> P DAppmved )Approved With c ondition6 ®Disapproved <br /> L <br /> A See Attachment With Conditions) <br /> N Pion Reviewers Nam a <br /> Date-1.12—,11,01 �" <br /> Ole r <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE MTN SAN JDACUN COUNTY OROINANCE84 STATE LAWS,AND RALES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY.IFNVIROMMINfrAl.HEALTH DEPARTum,OWNER OR LICOMD AGENr'S 81ANAluRE CMFIE6 THE FOLLOWING "1 CaaRTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK Polk WtkH THIS PERMIT IS ISSUED,I SHALL NOT]EMPLOY ANY PERSON R SUCH A MANNER AS TO DECOMI SLWWTT® <br /> COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUBCONTRACTING SIG"kTURffi CERTIFIES THE FOLLOWING: Z CERTIFY <br /> THAT IN THE PERF OrTHE WORK FOR WHICH THIS PEIMtIT IS ISSUED:I SHALL EMPLOY PERSONS SU9JUCT TO WORKER'$COMPENSATM LAWS <br /> OF CALWORNIA <br /> + ,► 'rare tuxru"U.3 .c� .G (� <br /> BULLING INFORMATIO <br /> Indicate the responsible party to be billed ror additional END start Ante expended beyond 1501mil payment Coverage per tank. H <br /> Dw party dvAgn led below is different than the permit applicant, e.g. properly owner, the party mull knowledge tlAg <br /> resp�,�iw'tar`►"� <br /> bil` g"ky for the biiby eigrOure and dale . <br /> N _l_ �.'h� `ttv <br /> .,...— ;��i__c Lr•L�;,j11�1�.,t��PNONE A "!�d • 'a�•�i�b.-,_�d ��T � ' <br /> SIGNATURE <br /> EN230M(raviw 12131107) <br /> Y <br /> 900M vhmv oauv m ZC90 ZZS 5Z6 YVi 6C:60 6002/ZZ/ZO <br />