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ENVIRONMtNTAL 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# C-A j o0o z�?f-/S& Project Contact&Telephone# 44,kG C7rz.J an CZ-9 993-574 <br /> C Facility Name i/c, Phone# (L�S) 5�3-87�� <br /> Address 53a <br /> TCross Street <br /> Y Owner/Operator Vy i o ct (2 Phone 2- `i YY- FV/Z_ <br /> D Contractor Name } �ja Phone# <br /> O jet✓n Co uw N ✓`4L <br /> N Contractor Address I 'C . ox �33$1- CA Lic# `/9 /oS3 Class J> hf ti <br /> A - <br /> Insurer S --,- c F�h Work Comp# S /13-7 /P <br /> ICC Technician's Name Sos S r1v/wlov+I Expiration Date 1 /13 /tot k <br /> oICC Installers Name Tos S,y„�.,,,aH Expiration Date //u <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak dettene�mr,UDC 1/2,etc.) 1, Installed <br /> T Vµku GcO SCG�NKuµ. • I( <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With conditions ❑ Disapproved <br /> L ZA achment With Conditions) <br /> N Plan Reviewers Name !t 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 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." 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 CALIFORN LA.' <br /> Applicant's Signature Title lY' �� Gxa =� Date <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 and date below. �y c <br /> NAME /"`/lG G 1 t 4,( 11 TITLE Lu �IOc(L PC 04w 6- PHONE# <br /> ADDRESS ISIZ WGS T rc l� l�cv" cf2lr <br /> SIGNATURE DATE <br /> EH230038(revised 12-11-15) 2 <br />