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ENVIRONMENTAL HEALTH DEPARTM <br /> E� <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 i 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 'IRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT F)EPARTMENT <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# <br /> A �1 <br /> O Facility Name —7— � � g�� Phone# <br /> L Address 4f'9 41. S j, /55f/ 4C C <br /> I <br /> T Cross Street <br /> Y Owner/Operator '�— � � Phone# <br /> C Contractor Name 1 ` 77�— <br /> Q �C d S r Phone# � p 'Z— -7 <br /> N Contractor Address 0 <br /> T 3�� <br /> R ti► CA Lic# "771 2-6 7 Class�,'�L <br /> A Insurer /'�- <br /> C S'v/ C� e'O� Work Comp# 10, �'L?S-Z <br /> T ICC Technician's Name Lps. , <br /> _O °O Expiration Date <br /> R ICC Installer's Name ® p �bLp� n O VN Expiration Date <br /> Tank system work area !y <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Tank Size Chemicals Stored Currently Date UST <br /> pp , Installed <br /> x <br /> T 1 " CS <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions <br /> L ❑ Disapproved <br /> A (See Attachment With Conditions) (� <br /> NG Z !0/13/;,d l / <br /> Plan Reviewers Name v kit /1 l -^�— l 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 PERFORMANSP 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 C S C-C� <br /> • 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 ffforr t e billing by signature and date below. / <br /> NAME C/,, G_ .� C—e— TITLE G— ����S <br /> ^ ' PHONE# � /`-/�`7 —17?0 <br /> ADDRESS �Qv 97 /V V�/cI le <br /> SIGNATURE__ DATE � Ti� <br /> EH230038(revised 07-17-2014) <br /> 2 <br />