Laserfiche WebLink
9 • <br />RECEIVEEI 03/04/2012 22:16 2094785509 PACIFIC CAR. IFlA�H <br />0+/05/2012 10:07 9163731.173 WALTONENGINEERING PAGE 01102 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JO.AQUIN COUNTY <br />600 .Fast Main Street, Stockton, Caittfbrnia, 95202 <br />Telcphone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THS dERhA1T BX0006 180 GAYS PROM THE APPROVAL DATE, INDICATg 0R*MiTTYPS BE-WM! <br />❑ TANK RETROFIT I PIPING REPAIRIRETROFIT ❑ UDC REPAIRMETRORT u CCLt! START/EVR UPGRADE <br />1 X <br />EPA Site <br />Project Contact 4 Telephone 0 Tanya T. 916-373-11153 <br />i <br />Fadi ty Nomep _ <br />pebm - <br />- - k <br />Address 4405 if. <br />IT <br />Goss Street <br />I Y <br />Owl?'WPembr Pacific Car Slash I Phoma 209-.478-5504 <br />C <br />0 <br />Contractor Name rgalton Sagineering, 2rc Phone# 916-373-1165 <br />j <br />I T <br />Contractor Address P.O. Box 1025 <br />CALic# 617238 Class A,8 Haz <br />R <br />. A <br />Insurer Praetorian <br />Work Comp#Q1�4~4006s74. <br />c <br />ICCTevhniclan'sName see attached Certifications Expiration Date <br />R <br />ICC installer's Name <br />Expiration Date <br />Tank -1-11 work areaDate <br />'La a7 PNMeLYAP.9:laadalww LrC 11x, or.) <br />TdnK Sixe Chemicals 5tvred (iumently USI" <br />installed <br />Aisp # 9-10 - Repairs to <br />piping belour the shear valve. Reg1. c* <br />A <br />Flexx COt'lX1.ector. <br />N <br />I <br />I <br />� <br />i P <br />❑ Approved <br />roved with oondidor* _1 Disapproved <br />L i <br />A <br />(See Attachment With Carxlliians) <br />N <br />P:an Reviewers NameD� <br />,. <br />T I <br />APPLICANT LW,ST PERPORM ALL WORK IN ACCORDANCE VW" 6AN JOAQUIN WUNTY ORDINANCE$, STAT: LAYJS, AND RULES AND REGULATION$ OF SAN j <br />JOAQUIN COUNTY, ENVIROm emTAL MEALTH DEPARTMENT. OWNER OR LICENSED AQF rb arONATURE Ceftnl-ms THE POLLOWING: "I CER71FY THAT IN � <br />THE PERFORMANCE OF THE WORK FOR VMICH THIS P01WIT IE ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A nMNNE'R AD TO WOME SV949CT <br />TO MfAKA S COMPSNBAMON LAVA QF CALIFORNW' CONTRACTOR'S kIRINC OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCLLOW'NC: ^,I CERTIFY <br />TWIN THE PERK MANCE OF TME WORK FOR LM ICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS 91JIWECT TO WORKERS COMPENSATION i.AwS <br />OF CAUFORN{A " <br />* i APPlleant'a ^Horta4no TiUc �w I\}EWL <br />Indicate the responsible party to be owed for additional END staff time expended beyond perm$ payment coverage per tank. if <br />the party designated below is dlfFerW dtan the permit affleent, e.g, property owner, the party must edkmdwiedge this <br />respon�a-byil�Ry�ir�sr t�he�billi+n�g-by sign�aWrre and data below, �. <br />-i NAME 1 ANI t4A- � . TITLE Owner PIHONFe� 1T����"o <br />ADDREss 4505 Pacifyi�c Avenz:s, Stockt orl, CA 95207 <br />SIGNATUR CA 1_...1 -DATE, <br />EIt,^3003$ {revised Dzm6a) <br />1 <br />'13/tt+ 3rmd <br />HS'*! 6V_i DIJIOV,:15O>58Lr6c,� r • 60:,_7, c, <br />'TG• irt3,._C+ <br />