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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 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# 60L JrIty� 7d7 2-73-218& <br /> A <br /> G Facility Name E Phone# <br /> � Address o?qw idar L~ UOi (24- q,.S Aa- <br /> I Cross Streets , `� 7b <br /> T <br /> Y Owner/Operator if�` ' 'Ei 'tC_IiR;l/v� 4 Phone# <br /> C Contractor Name Phone# <br /> Q /I'l.�ii1/r �/4�tX�. G <br /> N Contractor Address ) CA Lic# Class y+ <br /> A Insurer /��,�". t (;9 V1i f, �7-1-(LI C.cJ.YWork Comp#GVPIL bL'iGG^GJL�';Z <br /> TICC Technician's Name Expiration Date <br /> Qnstaer's Name /M/ALE Ex Expiration Date <br /> R ICC IllNp 4/-►7- 26 11 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T Fn'1 rii�Wl `1/ N� ✓ ✓ 10 Ocu <br /> A <br /> N <br /> K <br /> P r Approved Approved with conditions Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N / <br /> Plan Reviewers Name v 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 <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 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 /> TITL <br /> NAME ('/Z!C //�!✓L�A. (s ��q�C %�i�biONE# ,2 <br /> I <br /> ADDRESSt-�2y /Zi41&`V/lti 90,5/I 6+ 9 5 qQ3 <br /> SIGNA RE DATEyLI <br /> _I� , l/ .2C'f() <br /> EH230 8(revis 02/20 <br /> 1 <br />