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ENVIRONMINTAL 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 /> ❑TANK RETROFIT D PIPING REPAIRIRETROFIT U UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 510 _:73q - l.))) <br /> APhone# <br /> C Facility Name S Je ✓ <br /> I <br /> L Address '1.0 b vv�i JCS c"n.A Gjs 7� <br /> TCross Street <br /> Y Owner/Operator j S Phone# <br /> oContractor Name Phone# <br /> N Contractor Address CA Lic# Class <br /> T <br /> R Insurer Work Com '# <br /> A <br /> G ICC Technician's Name Expired Date <br /> T <br /> QICC Installer's Name Expi Ion Date <br /> R <br /> Tank system work area Tank Size Chemicals Stor d Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> 7 OL�}av�e S vv" 00 «.I roc , a a t <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN C NTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICEN ED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHA NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRIN OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS ED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title ' Date <br /> BILI!(NG INFORMATION: <br /> Indicate the responsible party to be billed for additional HD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the p rmit applicant, e.g. property owner, the party must acknowledge this <br /> responsibilit2the I(�/iing by Signature and date below.NAME �l� �. �" TTITLE OW11? f PHONE# <br /> ADDRESS w" X osq, �e_/ v�- n�. 'r�17✓+. , C,4 -33 <br /> SIGNATUR -DATE�� 7�^ 2-o 16 <br /> EH230038(revised 12-11-15) 2 <br />