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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> OEC 222017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> D TANK RETROFIT K PIPING REPAIR/RETROFIT Q UDC REPAIRIRETROFIT ©COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ff <br /> Q Li6s <br /> G Facility Name O Phone# <br /> Address 3250 ,,,+ , (,A 3 0 Lf <br /> TCross Street a 10 <br /> Y Owner/Operator �+ W���P Phone# y S 4 <br /> oContractor Name &)64VN Qevr —Tic Phone# (11 ho <br /> T Contractor Address i v s'� �b S CA Lic# 3CQ 34S Class A <br /> A Insurer 1Q Co Work Comp# QdC <br /> C ICC Technician's Name <br /> T y • Expiration Date oq <br /> ° ICC Installer's Name <br /> R %( N Ylr Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 112,eta) Installed <br /> T a 3114 q11,0 <br /> A Tl or <br /> N <br /> K ; <br /> 71 4a <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 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." <br /> Applicant's Signature Title f S,/rrT7 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 - r r A cji TITLE S7la�ry l i Irh�7S� PHONE#. j?W19 664 <br /> ADDRESS__j0 Grr. _ii Pis GL vxyy,s�., <br /> SIGNATURE DATE_ <br /> H230U38(1 <br /> evi 10130112) <br /> 2 <br />