Laserfiche WebLink
yk <br /> ,-s a. <br /> r i IIj <br /> S A N J 0 A Q I I I N Environmental Health Department <br /> COUNTY ' �1 OCT 0 4 2013 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK NVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPAPT �.4ENT <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 # C /A L 00 0 -L SOL q 3 O Project Contact & Telephone # 6vaj&( ✓ "c 4ec ? LQcm ) y3v�p8o <br /> C FacilityName A '\ F A 7%P1 ' , Ai lqv + � orq ;,� Phone # Zoe Y3 S_ �+ r; �} <br /> I AddressZ 1r- 3 S S . t tNvs �• � qac CSA 9 �' 3 <br /> L <br /> I Cross Street S'$ 0 <br /> T <br /> Y Owner/Operator Je i 1 1 � Phone # X51 a� 249 , t 2 t 9 <br /> C Contractor Name `� t Q vin Q„� Ike o (e v , ., S� •, ce4 Phone # q 2i) y -OR 03 <br /> 0 <br /> T Contractor Address 6 � � , �� � (� (� SN�b CA Lic # / OO SLf y Y Class A <br /> AInsurer 5 -f�-a � c Co .n,. �,," 4 v4� .sv.cCa1" c .c. r, n Work Comp # ��I 2 / y "} �3' — <br /> T ICC Technician's Name V S �-tC (1 Expiration Date y - jyw _ zo 2 <br /> oR ICC Installer's NameL1 Expiration Date ZOz I <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 [oak detector, UDC 1l2, etc.) Installed <br /> T <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L 5ta ttachment With Conditions ) <br /> A ; <br /> N Plan Reviewers Name - ate - Date <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 AGENTS 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' 1 <br /> Applicant's Sig TiUe ra"n ` "- <br /> ' ec c Date J 0 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e .g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date __below/. l <br /> NAME P/ 0M LM de r'o/eym ge ✓ i cel +T�, TITLE Cirn"7Ya 'c"�' PHONE # C 7w"5/ y �a __ wO P 0 3 <br /> ADDRESS l "� tUC C� 7 ! -� 0 S� <br /> 42 <br /> SIGNATUDATE / y <br /> 2 of 6 <br />