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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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> AFacili Name ilk-31— <br /> C ry 9(- ft-S t, Phone# <br /> L Address S 1 bGk 1 6 n Clk- 7 n <br /> 6 ;3-/2- <br /> TCross Street <br /> Y Owner/Operator 6 L cmi'pf kh Phone# <br /> o Contractor Name /,O 04,11!yCvkts,04 Phone# <br /> T Contractor Address f J Q Z B azim ca n l lrf CA Lic# FIaZ Q Class ff <br /> R Insurer Work Comp# <br /> A <br /> T ICC Technician's Name 'Or- Cve t2+sra a Expiration Date Q <br /> R ICC Installer's Name n1w/f- Expiration Date 9 �� <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detecbr,UDC 1n.etc.) Installed <br /> T Vf2 saa <br /> N <br /> K <br /> W {,lr� int <br /> ti lc <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 /> 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 PERFORMAN F T E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' //jJ <br /> pplimnt's Signature Title ✓— 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. <br /> NAME F457 t- `�`�y TITLE do'"'V' PHONE# <br /> ADDRESS—/ 8 " I 7 n <br /> SIGNATURE - fh' —DATE // - 12 <br /> EH230038(revise 2-11-15) 2 <br />