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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 />F <br />EPA Site # Project Contact & Telephone # <br />A <br />C <br />Facility Name GeA C4, <br />Phone # <br />1 <br />Address �3q`f (, `�C>SP_/neTr <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator P ^; �� ( ^ -j <br />Phone # <br />G <br />0 <br />Contractor NamePhone <br /># <br />T <br />Contractor Address �� _,.._ __ CA Lic #Oji 2 'L Class ff /0 <br />R <br />a <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Name Ott e4 Mormv <br />Expiration Date <br />o <br />R <br />ICC Installer's Name c y t r <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(Le. 87 piping sump, 91 leak delector, UDC 112, etc.) <br />Installed <br />A <br />N <br />K <br />P <br />LJ Approved Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name A Date Z��t <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 <br />TO 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 Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME r( -&;J /J,&n TITLE jf j.),n l' PHONE # ZGU 5'— <br />ADDRESS L� -/ �.J� ll �' C �/�1iT CC� 63' <br />SIGNATURE DATE <br />EH230038 (revised 07/22/10) <br />0. q <br />