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.. — �75— <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <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 11 PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT XtOLD TART/EVR UPGRAD <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> D Facility Name ' /.J Phone# --�U <br /> L <br /> Address 5-0 <br /> TCross Street <br /> X Y Owner/Operator Cc <br /> Phone# <br /> C Contractor Name K i jedc, P Phone*_" <br /> noN <br /> T Contractor Address P<O - CA Lic# gS9S"3 y— Class Zt <br /> A Insurer <br /> work Comp#k tP KC,C&p <br /> T ICC Technician's Name <br /> I1 S-4 sa 3 t Fr Expiration Date q-,Xo —(3 <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.97 piping w p.9/bet Oelecmr,UDC 12,etc.) Y <br /> Installed <br /> T <br /> ^ N <br /> D K /1 <br /> P ❑ Approved w Approved with conditions ❑ Disapproved <br /> L <br /> A (Se-°H-^hment With Conditions) <br /> XN Plan Reviewers Name_ 11V7 1,�//�Zit _ _Date_ <br /> r <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THEW K FOR WHICH THIS PERMIT IS UED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION S OF CALIFORNIA." CONTR _R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN 01 THE WORK FO <br /> OF CALIFORNIA" PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOR R'S COMPENSATION LAWS <br /> n� ,I <br /> AppLx=Ws S Title --�' \ Date G-f/ <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 admowled a this <br /> respon ' the billing by signature�FIQ date belo <br /> X NAME /Y�A) D^) / i / Lr'T�. (ij �u/�t�C� <br /> PHONE 7�f <br /> ADDRESS <br /> SIGNATURE DATE tC7—aS tL <br /> EH230038(revised 0811/11) <br /> 2 <br />