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ENVIRONMENTAL HEALTH DEPARTMENT <br /> RECEIVED SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> AUG 2 5 2017 Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ENVWiONMENTAL HEC CATION FOR UNDERGROUND STORAGE TANK <br /> DEPARTMENT ^ETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT D PIPING REPAIRIRETROFIT O UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project contact&Telephone# ?A a L4 40 w-�4 7 <br /> C FacilityName ` q q #-aS7I Phone A ao QS(o-Q3QQ <br /> Address '+ai 4 I`{0 r6-d.a.- L&�L-'f -bell IG1A. (!If rcal-1 <br /> Cross Street <br /> T <br /> Y Owner/Operator Phone# q14,37-3— 4-Sa V <br /> Q Contractor Name �b� �,ttL� Phone# gyp—a,[ <br /> O <br /> N <br /> T Contractor Address 'Z2,a„4k r Q CA Lic# '3 leti Class 15 Xtto a 4r?, <br /> R <br /> Insurer $ &&, Work Comp# <br /> ICC Technician's Namea �pV$� Expiration DateVirg/e20L <br /> D <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (l.e.07 piping sump,91 leak d.t r.UDC 1R,mm Installed <br /> T <br /> A <br /> N <br /> K <br /> 01 <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 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 /> HE 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: "I 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 /> M. L u &a Appll�nft Signature <br /> 10-4 (ZIN r7 <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 /> responsibilityfor the billing by signature and date below. ��,'.•_1 �/ .L Q q <br /> NAME Ak++V-T'tW /A{Vt' W�LTUKMJrTIITAbULU`LQLL�/Q�Q lk PHONE# �L�`� - -�O U� <br /> ADDRESS LP9 V (k4AIt, /'1xt 'S�.L.l,l -Jd&A <br /> SIGNATURE�'1 L27 1) ✓V,-t4LaJJAL.) DATE <br /> EH230038(revised 7-26-2016) 2 <br /> I <br />