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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Fast 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 18o DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT,$ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTlEV'R UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #�je,t. <br />/�/d•'i3 /r `Y <br />A <br />c <br />Facility tyName zr� 2-I'` <br />Phone # <br />I <br />L <br />Address, <br />/� yA � 1J a0 <br />I <br />Cross Street CC' <br />T <br />Y <br />Owner/Operator c- dY z', <br />q / <br />Phone # <br />c <br />Contractor Name <br />Phone # <br />T <br />Contractor Address 9 s'- r y �� ..Se�.� f ,�y;G �b <br />CA Lic # <br />S000 el Class -,L s �lJ�i <br />A <br />Insurer s �s� / XAj- 63 <br />Work Comp # QQ <br />C. <br />T <br />ICG Technician's Name , ysss �; r'd% �� <br />Expiration Date <br />R <br />ICC Installer's Name dL%� „� ,�'• //� ��7 <br />Expiration Date ;, <br />Tank system work area <br />(I.e. 887 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions <br />❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />40UIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />)RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA." <br />Title X -r 4ZO <br />BILLING INFORMATION: <br />- /Y—/ 4� <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 />f� �^ Jam• <br />NAME ( ' '7 V *Z Cr / G°�'',""l �4 � TITLE& =-t !!�' YC -/4 �'� PH©NE # <br />ADDRESS . 'dei i{�7 <br />SIGNATURE <br />/VLA <br />I <br />yr <br />r� em <br />DATE <br />EH230038 (revised 08/1 <br />2 <br />