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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 REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# /1t/ke Son <br /> Facility Name a uc F C f:y-uKo JQ-IJt Ca. (e,cit Phone# 3 <br /> I <br /> L Address /�Z`( i�vr�vo V4-v-� �ac�cfo•� Ss zoo. <br /> T Cross Street w <br /> Y Owner/Operator Va ( 4�� �'�� 1'2t4-r-o I,r-ti,, Phone# 91 f3 S-7 `i3 <br /> o Contractor Name I<Cvh Cocom Cou Phone# &1,1 Zo-S Sof L <br /> T Contractor Address �p ` o�� �14«��� CA Lic# `/$I 1953 Class A- <br /> R Insurer Work Com # <br /> A S*{c_ Ctac o., r s u�u t=K p q —3 S <br /> T ICC Technician's Name j JY.c v's <br /> Expiration Date <br /> Qnstaer's Name i Ex Date <br /> R ICC IllNExpiration r vt.tn.o o'!r P 1111113 <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 I �— ZQ� • <br /> A <br /> N <br /> K <br /> P rovedlpproved with conditions Isapproved <br /> L ( ttachment With Conditions) <br /> A _ <br /> N Plan Reviewers Nam Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC SAN JOAQUIN COUNTY ORDINANCES, WS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEP ENT.OWNER OR LICENSED AGENTS SIGNATURE CER ��HE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A1C174W R AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS ALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE HE <br /> T OWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF ORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S CO TION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signat., Title 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 acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 07/22/10) <br /> 2 <br />