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ENVIRONMENTAL HEALTH DEP WTI <br /> SAN JOAQUIN COUNTY IOD <br /> MED <br /> E. Hazelton Ave., Stockton, California 95205 JAN 19 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE T/ 34KIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 3/L g gZ 8/ 93 <br /> C Facility Name -FP,P,ic, a L.Vb CE-.(EvP—c v\. Phone# <br /> � Address 37-7r /✓ —IjeACV 6 LVD <br /> TCross Street <br /> Y Owner/Operator c- D 11111C. Phone# <br /> o Contractor Name em(7t C-VI`ZP Phone# 310 g 4 Z S193 <br /> T Contractor Address •Z3 p �7 'jj�114-11" ✓E� CA Lic# Cl $g` ' Class <br /> R Z <br /> A Insurer Work Comp# <br /> T ICC Technician's Name f5 4 <br /> I2.-¢1in WL OU `IExpiration Date <br /> R ICC Installer's Name <br /> E71l ryl 0 LI N I'f Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e.87 PIPM9 SUMP,91 leak detectap UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> 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 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 PERFORMANC HE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> A Co MC.0 fb✓. <br /> Applicant's SiB�aNre 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. p <br /> NAME 0W 61E-L- yyl OL-It IV� TITLE ('CJ�'l"IY�V"CfiD� PHONE# 310 917- V1 1,3 <br /> ADDRESS 12 3 0 8 P 0 W*1-0—y 19VC- [�l,✓y�, epi C7��'Z t4 Z <br /> SIGNATUR DATE <br /> EH230038(revised 7-26-2016) 2 <br />