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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <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 <br />EPA Site # L h 1, <br />Project Contact & Telephone # b <br />Facility Name ��%�� <br />Phoneb &5?_ 3 <br />�Address <br />�� ., <br />I <br />T <br />Cross Street ' 7` <br />Z- <br />Y <br />Owner/Operator RAlyi <br />Cab <br />Phone # - `— <br />ontractor Name C tis <br />e—P <br />Q <br />TC <br />actor Address F. <br />'C # Class <br />R <br />A <br />Insure C �' <br />�.C%L/� <br />Work Comp <br />c <br />T <br />ICC Tec ian's Name T <br />Expiration Date <br />RICC <br />Installer ame •�� <br />'— <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />Approved with conditions ❑ Disapproved <br />L <br />(See Attach ent 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 OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE F 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 COMPENS TION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOR NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />/� <br />7 <br />n^ "`✓ <br />Applicant's <br />Signature ' V <br />Date <br />Title C� G� <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 />P,it/ <br />NAME_I / yv 1 l ' b TITLE PHONE #_2(� 3- <br />ADDRESS <br />ADDRESS 5 -?A <br />SIGNA <br />EH230038 (revised 10/30/12) <br />2 <br />TE 1 ` Z ` �T <br />