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• ou <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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> Facility Name Phone# <br /> Address 7 t" <br /> 1L 2 cecu4 <br /> I Cross Street <br /> T <br /> Y Owner/Operator U ,vt ryt dLe {�Mf t\j Phone# <br /> o Contractor Name . L, (` Phone# <br /> N Contractor Address <br /> T CA Lic# Class <br /> R Insurer a yy6g ��.. ��" Work Comp# <br /> C - <br /> R ICC Installer's Name 11 Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e.87 piping sump,el leak cetecia,UDC 12,eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A M �y �l�tdY 1,� <br /> N Plan Reviewers Name -'GlQ_U 12 1 ' � 7n7 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 /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECTTO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> ppllcanfe Signature T.. % ri� Date 2-1 <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 <br /> ,(and <br /> edate below. �7 <br /> NAME MIA ala- !1`" <br /> E ?4iJ•AIYTITLE (7W PHONE# /• /i`� '���/ D" <br /> ADDRESS 77LI " .Y G "Cle N <br /> SIGNATUREIf <br /> EH230038(revised 10/30/12) <br /> 2 <br />