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ENVIRONMtIVTAL 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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />n Te NIC RETROFIT ❑ PIPING REPAIRIRETROFIT VUDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Protect Contact &Telephone # C' c� r r <br />A <br />`Facility Name L,,, p � <br />a Phone # f 99- �yU <br />Address 15 s G o <br />on Q63 � <br />TCross <br />Street 'r <br />Phone # <br />Y <br />Owner/Operator 3a , <br />Contractor Name <br />Phone # $d'j— <br />c <br />o; <br />N <br />Contractor Address p {''' <br />T /,jgr CALic# Class <br />R <br />Insurer 5 Cq� (1S l i l <br />Work Comp # 1%01 7.20 ( 2- <br />ICC Technician's Name <br />Expiration Date <br />T <br />R <br />ICC Installers Name - hCC�IS Expiration Date ((� <br />Tanks stem work area <br />y <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />e7 piping sump, 91 leak detector, UDC 112, MO.) <br />T <br />A <br />N <br />K <br />❑Approved <br />Approved with conditions El Disapproved <br />FN <br />(See Attachme With Conditions) <br />(o Z 9 <br />Name <br />Plan Reviewers N <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: "1 CERTIFY THAT IN <br />I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />OF CALIFORNIA:' <br />�rro /1/l /A Dele <br />Indicate the r,�l oonsible 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 <br />by signature and date below. <br />-I% <br />NAME IL�� l caY(� TITLE <br />f r r c- A— 1 1. h/ I, -P C—\ <br />EH230038 <br />1 <br />axL <br />