Laserfiche WebLink
SAN JOAQUIN <br /> Environmental Health Department <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # / f 4) Aocr 3 ` Q 9 <br /> Facility Name ���� Z Lf}-� `7 Phone # <br /> Address13 L � � e0 �L U 4L601CV 69 7v C% <br /> ICross Street <br /> T S� <br /> Y Owner/Operator ZL Phone # <br /> o Contractor Name r1s ) IRj ) 1 4V4 eAj I C� C9,0,5r Phone # <br /> N Contractor Address _Q o CA Lic # Class <br /> T <br /> R Insurer , 01 i fa-fi ��}- , Work Comp # <br /> C <br /> T ICC Technician's Name f ff-� , j��f Expiration Date <br /> RICC Installer's Name �fe°I � Expiration Date 7 .� <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br />(i <br /> E <br /> i <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A ` <br /> N Plan Reviewers Name Date-43 <br /> APPLICANT MUST PERFORM ALL WORK INA CE 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, 1 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: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> i OF CALIFORNIA." _ <br /> pplicant's Signature _ Title � � Date <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, <br /> NAMEPS T/tO,� rr� l TITLE M � ' '"' PHONE # <br /> ADDRESS J ` � ^ J �, r �� d ✓7.d f P! ( L� CrJ <br /> SIGNATURE ,�"'-- _ ---�� DATE r <br /> 2of6 <br />