Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephone: (209)468-3420 Fag: (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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# AtCOA1,t Wkcf-w %6.3�3 -a s <br /> A <br /> C Facility Name ( ( 0 Phone# l6 - W3 _ e g <br /> � AddressZ- <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator T C 1- v oM C L Phone# C//6 - T J Q F f- p <br /> 0Contractor Name <br /> o A Phone# qe6 - 3 a-3 <br /> T Contractor Address <br /> R S S'6`� � <br /> t CA Lic# / -2.3 Class � <br /> A Insurer g-r- j-E F Work Comp# ;L 13 . q q Z:. Z OCR <br /> T ICC Technician's Certification Number <br /> 1"1- Expiration Date <br /> ° ICC Installers Certification Number <br /> R ' " ®` Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T ( Z ® 0C` AC rLnN� <br /> A <br /> N Z / ® V C� <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name v' `1 Cs Date oc� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN 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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF E WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title d R �— Date ®Z 3 <br /> 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 /> responsibility for the billing by signature and date below. <br /> NAME t L ( TITLE l , (Z P- PHONE# 976 - 34-3 <br /> �-- <br /> ADDRESS / Z S-- ) S C D— S '� <br /> SIGNATURE kkA <br /> EH230038(revised 12/31/07) <br /> 1 <br />