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RECEIVED <br />MAY 0 6 2015 <br />ENVIRONMENTAL HEALTH DEPARTMENTENVIRONMENTAL HEALTH <br />SAN JOAQUIN COUNTY RECETVM CES <br />1868 E. Hazelton Ave., Stockton. California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 APR 13 2015 <br />APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT PERMIT/SERVICES <br />THIS PERWT EXPIRES 180 DAYS FROM THE APPPCVAL DATE NDZA7E PERMIT TYPE BELOW <br />TANK RETROFIT -, PIPING REPAIR/RETROFIT ' UDC REPAIRIRETROFIT *-"COLD START/EVR UPGRADE <br />F <br />EPA Site # &C,0'31 C Project Contact & Telephone <br />A <br />C <br />Facility NameA Fc:, -,5n Phone 6y -,44:3 <br />L <br />1 Address 9 74 b -ex -r <br />T <br />Cross street L Q -D <br />Y <br />Owner/Operator A 'M;At Phone # <br />o <br />Contractor Phone # <br />N <br />r <br />Contractor Address CA Lic # Class <br />R <br />A <br />Insurer Work Comp # <br />C- <br />T <br />ICC Technician's Name �P- Expiration Date <br />0 <br />R <br />ICC installer's Name Expiration Date <br />Tank system work areaDate <br />, 12 Ott i <br />uoC.. <br />Tank Size <br />Chemicals Stored Currently <br />UST <br />Installed <br />T <br />A <br />N. <br />K <br />..... ... <br />P Approved Approved with conditions Disapproved <br />L (See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date- <br />. . ....... ........ <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 <br />T <br />CERTIFY THAT IN <br />:THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON fN SUCH A MANNER AS TO BECOME SUECT To <br />WORKER'S COMPENS ION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I <br />CERTIFY <br />THAT IN THE PERFor, NCE OF THE WORK FOR WHICH THIS PERMIT'S ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA <br />Applicants Signature _ Tte <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 desionated below is different than the permit applicant. e.g, property owner, the party must acknowledge this <br />responsi4i14 for the billing by signature and date below. <br />NAME1 �ALx4 jr-q4 A >z� TITLE_ PHONE <br />ADDRESS <br />'0 <br />3 <br />SIGNA <br />EH230038 (revised 07-17-2014) \�� <br />