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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 JUDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# -aq3Pjj— 4420�L <br /> A <br /> C Facility Name Phone# _ (�e� _ 0 l -? <br /> I Address <br /> L I lOb S. Mata h'lan�-�cq <br /> I Cross Street <br /> T <br /> Y Owner/Operator Kul c y Phone# Stb _ 1,,f5 <br /> 0 Contractor Name <br /> Cor^ Itcf\Ce ek _5 ' C. -o`i -54'S-4'ib� <br /> O <br /> N Contractor Address <br /> O, ('Oy 5 60 CCI`C5 9-3307 CA Lic# ��[{{,Z b�, Class <br /> T <br /> R <br /> A Insurer �� ,�,�,` �l Work Comp# ►vo Zmpl% y-"5 <br /> c ICC Technician's Name -Ecns� Ex (ration Date <br /> T lov ��f1 P <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (ie 87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T 4 ►l o✓L/� <br /> N <br /> K <br /> q � lvic <br /> P Approved Approved with conditions Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name AAA Date 63 1,!q� 3 <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 G. Date " 1 l <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_TC*A1 2 ++ TITLE�C��'�4Ci f PHONE# �p4-�45`q`�4i`� <br /> ADDRESS �.0 • 1�k 5t" Ce—t<- CA <br /> SIGNATURE DATE '- <br /> EH230038(revised 10/30/12 <br /> 2 <br />