Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"D FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br />--------------------------------------------------------------- <br />----------------------------------- ---- <br />EPA SITE $ PROJECT CONTACT & TELEPHONE <br />---L.a�.l [' o --+ <br />F 1 FACILITY NAME-----_----_-_-� PHONE # <br />A+---------------- - --- ------ ------------------ ----------------- - -- - -- -- <br />C I ADDRESS® T -- --®- -® ---- <br />/ //�.� /"''' _ <br />L I CROSS STREET <br />--- G -- -�---- <br />r <br />I1 --------------------- ----------------------------------------------------------- <br />{ T { OWNER/OPERATOR n�q �t d ® �` -------------' ---------- -- ----' --------i <br />Y I 05 7- C0 S% /�/ oouIli L.L.„ I PHONE 0 •� i <br />I+---------------r-------------------------------------------------------,------------+-.L ®g, ®Z 3 3 s 1 <br />{ C { CONTRACTOR NAME 'J` t� �/ - ---------------------- <br />PHONE 1 <br />0 +------- --- �-`---- ---- { N <br />N I CONTRACTOR ADDRESS p. ` ------------ <br />T------------------------�o -- L- n-�`�-- I CA LIC f! C/ { CLASS GI® / c`� lf/G� <br />{ R I INSURER - - -i <br />A I -- ------ - - - - ®-- t11J�7 /�®T I ------- <br />WORK. <br />--- <br />-------------------------------------+'-------------- <br />I <br />C I OTHER INFORMATION I <br />{ T +-------------------------------------------------------- { - <br />�+ //�� �ryy % _4j j ---%-------j-/------------------+----------------------------------------I <br />I PHONE � { <br />--------------+----------------------------------------i <br />I PHONE # 1 <br />+---111111111111111121111 1111111111-------------- ---------------------------------------------------------------------------I <br />I TAN <br />139- , 1 !�l<TANK SIZEi CHEMICALS STORED CURRENTLY/ PREVIOUSLY I DATE UST INSTALLED I <br />N 39_ <br />K 139- I 1 1 <br />1 <br />139; I I <br />! -II39�1 1111111111111 <br />111 I{I, 171111111111111111111IIT-IFf I, II I {I III 111 IIIII II _111-IT-IFF-11ll II, II, 1{{illil II <br />P I <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />I A { ` (SEE ATTACHMENT WITH CONDITIONS) <br />N I PLAN REVIEWERS NAME DATE r <br />+---IIIIIIIIIIIIIIIIIIIIII iI{1 II I1 II I II II I I I I I I I I II I IIIIIIIII{111 I III I III II I, I II Ili <br />I 1 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />I <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE { <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO { <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />I APPLICANT'S SIGNATURE: TITLE DATE <br />-------------------!----------- <br />, <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />p w es r Ca s 7- pRoa C Le, <br />Name_,Jo ,�r �,�} Address ra6r e_ r- Phone # C ° ) `x`133 <br />Signature, <br />EH230038 <br />(revised 1/31/02) <br />1 <br />