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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468 -3420 Fax : (209) 46 &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 EPA Site # Project Contact & Telephone # mes f/ 6yf6V6 <br /> A <br /> C Facility Name vPhone # vz' 9 <br /> I Address <br /> L 1103 171& t I <br /> TCross Street i' SSia .-� / v�✓ e <br /> Y Owner/Operator, � Ct�c te: �� Phone # q(lml <br /> o Contractor Name 'f4 ` Phone # rll& 6q6 t9b 90 <br /> N � CA Lic # Class <br /> / ST Contractor Address 0 vSur rv � ��1 Narlrloin � 3L/5 <br /> R � // / <br /> A Insurer iAQS71 IV44)46t 9 eD Work Comp # e41000 `+�1.3 ? - gf <br /> cICC Technician 's Name <br /> T 114 4/av„ eExpiration Date ity'� ;?�C Zeo <br /> QICC Installer' Name Al Expiration Date <br /> R s r cic a vv p � / I - 2A) 7,<> <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> N � ( J tAC � p � l o9 k <br /> K �i i ( ' to (ke `r I P K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S6XAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name � � tcul F / ; Date j J <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 /> / c„ <br /> Applicant's Signatures , Title .�T7a770 i M'7"I$ 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 � � w. � S � 41KOvtr/'v TITLE _ PHONE # 6l 1 j eiF <br /> ADDRESS Gtv1 t7ve JeA r7 Cts%• t� h�`l / j <br /> SIGNATURE DATE 90/ 1 <br /> :H230038 (revis 0/30/12) <br /> 2 <br />