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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 ) 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 EPA Site # Project Contact & Telephone # G,ytlS (�jl�rt ,✓ til/�, 4V6, ? <br /> A <br /> C Facility Name �tE� tift7cn 138 Phone # <br /> � Address ; q O 1 � kh Aresrya <br /> T Cross Street Yr <br /> Y Owner/Operator ffiewbv\ Phone # <br /> o Contractor Name T a �� qe ef L Phone # ( 6 y (o C1 b 80 <br /> T Contractor Address 30 ` IA (a * f�� � � c 5 yamejl -o CA Lic # 161:134yS Class / L D1144& <br /> R <br /> M4- <br /> R A Insurer -vPr c� < � � Work Com #e, -3' -7 7 — / g / <br /> C ✓..r <br /> T V1 ICC Technician 's Name All <br /> / Exp iration Date < , a <br /> �� HCS <br /> Q ICC Installer's Name Ex iration Date <br /> R AAjt ✓� � p � ej - 19 - Zo-Lo <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 1/2, etc. ) Installed <br /> N 7 e ( ( 6010 twit <br /> K �hCLke <br /> i <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S )e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name -E , 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 y� Title a , reie k-/ 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 /> NAMEgym.*# ( a (P )(Gtyl Vs .� TITLE_ � t�Y SL1Pn� S � PHONE #_ A <br /> ADDRESS C GiMI e uiVe C �u ►v�Pr+ 7 4 <br /> 1 <br /> SIGNATURE DATE /E;257- <br /> ` H230038 (revi 10/30/12) <br /> 2 <br />