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! i <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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> eA Site# Project Contact&Telephone# C <br /> cility Name � Phone# <br /> dress <br /> (� <br /> ss Street <br /> ner/Operator Phone# <br /> ntractor Name Phone# <br /> ntractor Address '• <br /> 1i�7 CA Lie# Class <br /> urer.. - <br /> _: T Work Come 9� -- I, 115 <br /> Technician's Name <br /> Expiration Date <br /> Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currentl Date UST <br /> 0.a.ar plain¢wW,91 look deto ,UDC 1(d,ek.) Y Installed <br /> _. . <br /> P ❑ Approved 13pproved with conditions ❑ Disapproved <br /> -_L- _ - -- -- - - -- (SeelfAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name— Date—_6,&k/` � <br /> �( <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'SCOMPENSATION 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 /> Applicant's Signature TRIe Date <br /> BILLING INFORMATION: <br /> -_ <br /> Indicate.the responsible-party-to be billedforadditional EHD staff time expended beyond permit payment coverage per tank. If <br /> the patty. designated below is-Afferent than-the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. �l� <br /> NAME E..1 ITF.LU C(1(1TRF\ 7T �S r YC�vI ``4m T TLL �P�fe.SrC�T� n{r(�1�P ) PHONE# Z1 R 01 g2b� <br /> ADDRESSE (.f <br /> SIGNATURE- �\ �1 � DATE 49-1 1n <br /> -6 <br /> EH230038(revised 08/1/11) <br /> 2 <br />