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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # �— <br />A <br />C <br />Facility Name C, k CVS .J <br />Phone # <br />L <br />Address <br />T <br />Cross Street <br />Y <br />Owner/Operator c,� .,^ <br />Phone # <br />C <br />Contractor Name n 1 war cG f �,�, Sc ��-r• c� <br />Phone # (- _ ,_,""- :r- i 5" 1 <br />T <br />Contractor Address ct c; �`� ^� I' �^ <br />CA Lic# G'�f 7 �� �` Class a ..3._4 <br />R <br />A <br />Insurer <br />Work Comp # <br />ICC Technician's Name �n�, <br />Expiration Date //.9 <br />T <br />,c ,� <br />DICC <br />R <br />Installer's Name <br />O/ nIP o✓/.,i <br />Expiration Date .5�2./// -{ <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved proved with conditions ❑ Disapproved <br />L <br />'(See ttachment With Conditions) <br />A <br />� <br />N <br />Plan Reviewers Name Date 1� /��. <br />APPLICANT MUST PERFORM ALL WOR A 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: '1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />+/'Q 7G / <br />� = i i C�iy.,�r�o �' '7 <br />Applicant's Signature Title C /�/'s� Date <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 signature and date below. <br />NAME c . _ / C Z,L /'--� ___TITLE_ c C_/, �/J�s __PHONE # •1' "�� <br />ADDRESS ! / L-� +�.0 I! C c 1��� /��iol_'(�/(- �.I` t /d r�_?2_1 <br />SIGNATURE �� —{-� DATE -�f/ 7Z/ <br />EH230038 (revised 08/1/11) <br />2 <br />