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1% <br />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 />RECEIVED <br />MAY 0 6 2015 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />THIS 7 <br />11WT MAMMJ=S 160 DAYS FROM THE APPROVAL DATE. N:)ZATE PERMIT TYPE BE: OVV_ <br />0 TANK RETROFIT C PIPING REPAIR/RETROFIT D UDC REPAIRJRETROFIT :1 COLD STARTIEVIR UPGRADE <br />F <br />A <br />EPA Site #C Project Contact & Telephone # <br />. . ... .... ... .. 16 <br />f <br />C <br />Facility NameA Phone tA6 <br />I <br />L <br />Address 74 b-eX-r CV2jq- <br />. .. . ....... <br />Cross Street --rila <br />-]:Y O <br />Eone �#ewner/Operator <br />0 <br />Contractor Name <br />—7 1Phone <br /># <br />N <br />r <br />Contractor Address CA Lic # Class <br />R <br />1 A <br />Insurer Work Comp # <br />C <br />T <br />ICC Technician's Name D��A Expiration Date <br />0 <br />R <br />ICC Installer's Name Expiration Date <br />Tank system work area Date LIST <br />(i 0 87 9, leak Tank Size Chemicals Stored Currently <br />poing Sum, uo(- 142. etc) <br />Installed <br />IT <br />I <br />A <br />N <br />K <br />- <br />----------- <br />....... .... <br />P I A, Disap roved <br />: Approved with conditions <br />e Attachment With Conditions <br />A W "h <br />I <br />N, <br />P1 viewers Name Date —.- <br />4H <br />ACCORDANCEvil T SAN JOA"UIN NTY <br />APPLICANT MUST PERFORM. ALL WORK A ACCORDANCE VVITH SAN J AQUIN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN I <br />OR' <br />JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO-WING 'i CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALT, NOT EMPLOY <br />1� <br />- ANY PERSON IN SUCH A MANNER AS To BECOME SUBJECT TO <br />WORKER'S COMPENS' ION LAWS OF CALIFORNIA " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATJRF CERTIFIES THE I 7OLLOVONG: 1 CERTIFY <br />THAT IN THEPERFOR NCE OF THE WORK FOR WHICH THIS PERMIT 'S ISSUED. <br />OF CALIFORNIA." I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Wlcat)Vs Signature y' T&A <br />M_2:11111111111:::�_ I . . . . . ... . . . ..... ... . ..... <br />BILLING INFORMATION. - <br />Indicate the responsible party to be billed for additional END staff time expended beyond permit payment coverage per tank. If <br />the party desionated below is different than the permit applicant, e -g, property owner, the party must acknowledge <br />responsihillav for the billing by signature and date below. edge this <br />I I <br />NAM —TITLE—. PHONE* <br />ADDRESs_S_7_4__ <br />SIGNAT <br />EH230038 (revised 07-17-2014) <br />DATE <br />