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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY L �; <br />1868 E. Hazelton Ave., Stockton, California 95205 MAY 2 6 2015 <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 STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact &Telephone # S-f—Lf y6/ 1 720 <br />� <br />I <br />Facility Name l , �{ 41 _ <br />Phone # <br />L <br />Address <br />I <br />T <br />Cross Street - <br />Y <br />Owner/Operator Z—e011 d? <br />Phone # %/ <br />oContractor <br />Name G G ��. <br />Phone # <br />N <br />T <br />Contractor Address 7 <br />3 �` L%Q <br />CA Lic #6% Class <br />AInsurer <br />C <br />Work Comp # <br />T <br />ICC Technician's Name <br />Expiration Date Z�_t-7 <br />R <br />ICC Installer's Name S <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />tttachment With Conditions) <br />(S AMaol <br />N <br />II ll <br />Plan Reviewers Name—EWR o 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANC OF TH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOR R'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />/� /� �l�� 1,i ,4-1 U <br />Applicant's Signature Till. LiV Vv�S na+a <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 rb signature and date below. <br />NAME 1 �� TITLE_�-li s1\} 4 CS PHONE #__— r <br />ADDRESS C�� 1 �. V C/Qy_ 'If�i ` "1`� 1372-2 <br />SIGNA' <br />EH230038 (revised 07-17-2014) <br />2 <br />M <br />