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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 PIPUG REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 0 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # y <br />A <br />C <br />Facility Name eVra <br />Phone # -7 q— _ u/ <br />�Address <br />D ' <br />1 <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # Zp SZ •-,�/3 <br />o <br />Contractor Name �f � <br />S <br />Phone # 7— c. <br />�� <br />T <br />Contractor Address c f <br />CA Lic # q�{ q 3K{" ClassA 3-v�f o <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name <br />O/�nf <br />�L.�/1 <br />Expiration Date �. <br />O <br />R <br />ICC Installer's Name <br />�Cc�i S <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, <br />etc.) <br />Installed <br />T <br />A <br />N <br />K <br />F, <br />Approved <br />Approved with conditions ❑ Disapproved <br />L <br />--(See ttachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORVN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF C/ALILIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THEWS, FOR <br />OF CALIFORNIA." <br />WHICH THIS PERMIT IS ISSUED, I SHALL EMPLO PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />L <br />_ <br />' <br />Applicant's <br />Signature *}— �� <br />Title CY /�/ '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. J <br />NAME ��o„/� Lc�ll�/�S TITLE /E C -G. I./�PS / PHONE# -?4-2 7—' /4 <br />ADDRESS <br />SIGNATURE /t ____��� DATE <br />EH230038 (revised 08/1/11) <br />2 <br />