Laserfiche WebLink
05/28/2010 19:11 2093651543 TANKNOLOGY PAGE 02/08 <br /> t <br /> ENVIRONMENTAL <br /> A DEPARTMENT <br /> MENT <br /> SAN JOA UIN COUNTY <br /> 600 04,2s#MMn Street,Stockton, CaOlIfornia9 495202 w� <br /> TeOep9 one: (209)468-34299 Fax: (29949) 468-3433 <br /> APIPLICA'>i iON FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM 111E APPROVAL DATE. INDICATE PERMIT TYPE 84LOW <br /> TANK RETROFIT [) PIPING REPAIR/RETROFIT n UGC REPAIR/RETROFIT COLD STAR T/EVR UPGRADE <br /> 1 E i="!�Site# I :l _ ProJact Gantact Telephone <br /> A Fsnili Name t ,.... ,.,..." f�hone..... .._._.._ ._. <br /> M- �ems_ I <br /> /address X75 vj P-5 <br /> T <br /> y Owner/Operator Phone 0 <br /> Contractor Name- 4,v 0 Phone#7 G�_31. <br /> T Cc ntractor Addressll I{� t�. �Co `"` (�, Sd�. 37-SCA Lic# Class <br /> Work Comp# <br /> IC',:'Technician's Nome <br /> Expiration Date <br /> IC!;installer's Name Expiration Date <br /> 'Tank System work area.� Tank Size Chemicals Stored Currently Date UST <br /> fi.(i.91 pipinq sump,01 NaN 0)(actar,UDC 1P2,Otc.) _ -" Installed ,+-s <br /> Approved " — " Approved with Conditions " Disapproved <br /> L (See Attachment With Conditions) <br /> A " ! <br /> N PkIn Reviewers Name _---, Date <br /> vAPPOCAN7 MUST P17-TTORM ALL WORK IN ACCORUANCE WITH SAN JQAQUfN COUNTY OROINANCUS.STATE LAWS,AW SUI.CS AND RE(juLArIONS OF SAN <br /> JOAQUIN QOUNI'Y,MI`,IVIRONMI4,rrrAl.I1EALTH DEPARTMENT,OWNFfi OR LICENSED AGENT'S sIGNAI"URG(:ER'I'IFIFS TNS FOLLOWING; "I CURIIFY"HAT IN <br /> THE PEWORMANCE OF THI.WORK FOR WHICH THIS PP..RMIT IS ISSU[O,i SHAU.NOT EMPLOY ANY PRRSON IN SUCH A MANNER AS TO 0r:COME SUOJEC1 <br /> TO WOPKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S MIRING OR SUSCONTRACTINC SIGNATURE CERTIFIKE THC FOI.I.OWING "I CFRTIFY <br /> THA'r iWI WE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSLAW.I SHALL EMPLOY PFRSONS SUBJECT TO WOHKFrYS COMPRN$ATION LAWS <br /> OF CAI.IFQFNIA," <br /> Applicant's Slgnalure._ _=_-�- Tide <br /> BILLING INFORMATION: <br /> Indicate the responsible party to W billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the pary dealgnated below is different than the permit applicant, e.g, property owner, the party must acknowledge this <br /> responsibility for thtr billing by signature and date below, <br /> NAME_ ,....TITLE_ PNONF. <br /> LI I23004(rev[srd 02/20/09) <br />