Laserfiche WebLink
SAN JOAQUIN Environmentaltt!qerEeN ED <br /> - - COUNT Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> JUL ® � z023 <br /> RETROFIT OR PIPING REPAIR PERMIT ENTAL- <br /> EN HEALTH <br /> VIRONM <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: P ERMI -V aRV ICES <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 4rf o ,+t+ , / (o qq3 - (o3L <br /> A J <br /> G Facility Name � /h GS c7 -Gn ss � 7�YG Phone # <br /> 3l - <br /> L Address WAJ*41/ 0b <br /> TCross Street ; C t v l<< <br /> Y Owner/Operator vroa s r i otvt n c Phone # <br /> C Contractor Name T <br /> Q L ul %JaG¢ J ' Phone # <br /> N <br /> T Contractor Address Lfqb 1 W�6Lot, cce w CA Lic # l D (Q � b� Class G (0 it&1 01( o <br /> R Insurer <br /> A it Co SJ � ,N+ ce ^� ✓k- C/� Work Comp # <br /> TICC Technicians Name <br /> T ' ( ��{j(� Expiration Date <br /> G <br /> R ICC Installer's Name Yjpr �,l Gam ✓ acs Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leakde(eclor, UDC 112 , etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name `♦ <br /> L� � . 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 THEWORT R HICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. " <br /> Applicant's Signature 40PTitle 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 responsibilit for the billing <br /> by signature nd date 4bellow, <br /> NAME �G� -tyt/ � TITLE 0 ' PHONE # <br /> ADDRESS, lO� lJ& (r1, V0V5_t <br /> SIGNATURE DATE <br /> 2of6 <br />