Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> COUNTY <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT 16 UDC REPAIR/ RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> � <br /> Facility Name ' (lI� C a ' r � Com` Phone <br /> I Address ( Ltojq S lV <br /> T Cross Street Cj,� y' wed <br /> Y Owner/Operator ,� L:,2 Phone # <br /> C Contractor Name ( e � +(,� `"f� c , Phone # <br /> 0 <br /> TContractor Address 3 � � CA Lic # 1 `F4 " Class <br /> R <br /> A Insurer Work Comp # <br /> C ICC Technician ' s Name (' Q Expiration Date <br /> T <br /> Q <br /> R ICC Installer' s Name Expiration Date <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 Sp <br /> K 1. <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name 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 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 : " I 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." �A � /, �.-, � I 1 <br /> Applicant's Signature i a LCLL1' Title ` Date �� ' { �a �" <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. J� 0 <br /> NAME TITLE �u ( " " PHONE # <br /> ADDRESS 6 S [ uL4 SatL And <br /> SIGNATURE �/ ' `�/-C i -�� DATE / oZ � /aOazL <br /> 2 of 6 <br />