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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 /> T L$PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETR .FY PIPING REPAIRIRETROFIT UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA She# Project Contact&Telephone# f�Y1 S vD " V <br /> � Facility Name \ W&D # Phone# eiii, gi1,13� <br /> L Address OAQ�3 <br /> TCross Street <br /> Y Owner/Operator Cs etI Sit 4 (C412A1 ati\ Phone# $p 0 • <br /> C Contractor Name —�-• 6Y1CtYx I Phone# $31.�.t"�S• Q01�\ <br /> T Contractor Address 2S�p �ZOb CA Llc Class <br /> A Insurer 6 y) Work Comp# O ll Oo t <br /> T ICC Technician's eme Z Expiration Date <br /> R ICC Installer's Name :F nw 6o'h _ Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> �y(l(s 87 nbng wrrp,eL leak detector.UDC v2,etc.) Installed <br /> T v� <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A ' i -,/ �- 06013 <br /> N Plan Reviewers Name, Date <br /> PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAID <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING 'I 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 SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Appllcanrs Signature ( WXLoMaDate 53Pa <br /> BILLING <br /> 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 and date below. a n� <br /> NAME vrvtin IAn 0)IA hCv'l TITLE C�tN,fX bI`I^^WU&Z VV-PHONE# <br /> ADDRESS Z51a0 Soq� AYc 41Z --an4"VL ✓ALL C' q i-D L <br /> SIGNATURE DATE <br /> EH230038(revised 10130/12) <br /> 2 <br />