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• • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RDE 0WED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 AUG 2 8 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMITMERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# i! 1 t�,r W t 1+V W-oatV ! Z <br /> A Phone <br /> C Facility Name Ra S 3 <br /> Address L f 0 9 q— CCL- LA'Lq L(L.14,51. C . <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# q 3 3— L 3oZ <br /> C Contractor NameA�j� µQS due— <br /> N <br /> Phone# �_ <br /> 0 <br /> N Contractor Address "j1aQ Lic# a+:� �� Class <br /> T <br /> R Insurer Work Comp# l Q`l a j <br /> A .._ tl,� , t D u�- <br /> T ICC Technician's Name cLrLl N SSV 5� Expiration Date <br /> ° ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> 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 0q ,) LlJ <br /> T— <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: "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: "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." i <br /> 1 <br /> l,u` CL' L w �i LL1.ar`'t' �4'Date � <br /> g �! (.t 1 <br /> Applicant's Signature u "'"`� �Lfl�.�itle <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. �/ 'L q <br /> NAME t alt W5 6A TITLE It PHONE# <br /> ADDRESS q SL -' <br /> SIGNATURE _�/ �/yL ' _DATE <br /> EH230038(revised 7-26-2016) 2 <br />