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ENVIRONMENTAL NMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 9520 <br />Telephone: (209) 468-3420 Fax: (209) 33 <br />APPLICATION FOR UNDERGROUND EPAIR PERMIT NK <br />RETROFIT OR PIPING <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT ❑COLD STARTiEVR UPGRADE <br />Project Contact &Telephone # <br />—3k V; <br />F EPA Site # <br />Phone #,e p, j _ y' <br />C Facility Name � <br />V G�q <br />I Address S � i <br />ef Z -9L <br />I Cross Street <br />Phone# <br />T <br />Y Owner/Operator ,<, ,g`(/ <br />Phone #� <br />c Contractor Name 0 <br />° <br />Glass <br />CALic# <br />%� <br />N Contractor Address,L n� <br />Work Comp # <br />T <br />R insurer <br />A <br />Expiration Date <br />C ICC Technician's Name <br />Expiration Date <br />T <br />° ICC Installer's Name Il <br />' Date UST <br />R <br />Tank system work area <br />Tank Size Chemicals Stored Currently installed <br />(ie- 87 piping sump, 91 teak detector, UDC 112, etc.) <br />T <br />A <br />N <br />K <br />❑ Approved <br />pproved with conditions ❑ Disapproved <br />P, <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS SAN <br />SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THH AT IN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS <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 />CONTRACTOR'S HIRING OR SURCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />WORKER'S COMPENSATION LAWS OP CALIFORNIA." <br />THAT IN THE PERFORMANCE OF THE WOIj1SFOR <br />ISSUE, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />HI HTNI$ PERMIT IS D <br />OF CALIFORNIA." <br />• <br />/ <br />Tilt. �[',I*fWj1,,#! <br />� BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank- If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signat re and date/below. � <br />NAME_ Jti�ze �/' , �����/� TITLE VA- q i/i7 PHONE #,7a <br />ADDRI <br />SIGNA <br />EH2301 <br />3 U 2014 <br />2 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />