Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"0 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 /> X TANK RETROFIT —PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> — ------- <br /> ' EPA SITE # cR LDODZ3A 9.63 PROJECT CONTACT & TELEPHONE # M $Ot+J /14 60,- 7.9 <br /> ------------------"-----"------ ------------------------------- <br /> 7-6LZVErJ $ 3t26z•----------------------------------- -PHONE ;; <br /> F i FACILITY NAME .2c9/15,5-a- 9117 - - <br /> A ,- - - - ----�-_---- 1 - A • ` p}� p �/ y cA 9537` <br /> C ADDRESS 23a/ W' G�YIJTIiI N _`F'y_ 1-�Sv-F- <br /> r <br /> L CROSS STREET Jbe-Yo wbo_-FAA!K'W�J---� <br /> T OWNER/�!'�'U'M"' P'r.O NE <br /> Y ; , r ?- t,�NErt I r tc - tog(4 y9 - %4" <br /> ------- /�/�(/ <br /> C CONTRACTOR NAMEM1� -yGrr��ER-��1GG��srt2.�cnvN.i-1�3c•------.--. <br /> G cA L I c # 7 /!� I�IE <br /> � N i CONTRACTOR ADDRESS • 23 3 LASS Z ��o <br /> T +------------ <br /> --toSCorAAic«�oopMSny_G�----�S��D� _ -9So_-- - - ,- --- + - <br /> ac.E -- ,CA9_ <br /> ' 'r�TEWORK.COMP.# <br /> R INSURER 5i � -------- -- <br /> -'7645" --O1 <br /> A _ knp _ _ _� -------'---'- <br /> C <br /> .-.. <br /> OTHER INFORMATION <br /> ------ <br /> T +_______________________ <br /> _____________________________________________________________I PHONE # <br /> 0 _____ ___________.___--------_- -________ -.. <br /> ---------------------------- <br /> R +_______________________ PHONE # <br /> ' M ! 111111111111111111111111111 <br /> INSTALLED _ <br /> TANK ID TANK SIZE# i CHEMICALS STORED CURR ENTLY�t DATE UST', � <br /> 39- :02W <br /> o 0 20 S 0" 4111 u�+r`keE� GasDLin1� �� <br /> e so I [0 000 t/N�-�_Ghspt,�ws <br /> T 39- O .► Gb C�. Soda 4% JgILy�$ <br /> A 3 9_ 0150:Z <br /> i0 i t0 UOQ G Aa. i..fwti— --- <br /> N 39 <br /> -- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9_39P <br /> ► AP <br /> _ APPROVED PROVED WITH CONDITION(S� DISAPPROVED <br /> L /T E� TACHM EDIT CONDITIONS) ` <br /> A �/ I O V V Vii. �' - DATE <br /> N PLAN REVIEWERS NAME ► <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGU'_J,:'IONS -F <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: . _. . <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY A-NY PERSON IN SJCH A MANNER ASv <br /> CONTRACTOR'S HIRING OR SUd CONT RF.CT?NG-ShG"iVTURE CERTI?IES THE <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHI C}i THIS PERMIT IS ISSUED, - 5}4ALL _. O. PERSONS SUBJE T <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE. .,ArV TITLE �P f Y _--- DATE _7/31 <br /> Ali_r_EN4_ '_coNs•—_-e_ --inr ----------------------------------------------------- - ----- <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 /> Named/ ' 4 , /NG, Address lo$60,60D i✓♦FY, Sv/T€ G Phone #9"%2l•4120 <br /> O C-64451 DE, G4 92054 <br /> Signature <br /> Cad o6-4 <br /> EH230038 <br /> (revised 1/31/02) +t ' <br /> 3� ms`s �''�'``� �'zC�� 1°�' 1��t��-• <br />