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RECEIVED <br />ENVIRONI /ENTAL HEALTH DEPARTMENW8 2014- <br />-AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />60( East Main Street, Stockton, California 95202 DEPARTMENT <br />Tell:: )hone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLIC -NTION FOR UNDERGROUND STORAGE TANK <br />RE, rROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT I: PI=2ES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 0 PIPING 31::PAIWRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />E <br />A <br />C <br />Facility Name ��; <br />I <br />L <br />Address 15 l <br />( <br />TCros's <br />Street <br />Y <br />Owner/Operator a I <br />C <br />Contractor Name <br />0 <br />T <br />Contractor Address <br />R <br />A <br />Insurer <br />c <br />T <br />ICC Technician's Name <br />0 <br />R <br />_ <br />ICC I'nstaller's Name <br />Tank system work area. <br />0.e. 87 piping sump, 91 teak detector, UDC <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />L <br />A <br />N <br />Plan Reviewers Name <br />APPLICANT MUST PERFORM ALL WORK IN ACC. <br />JOAQUIN'COUNTY, ENVIRONMENTAL HEALTH E <br />THE PERFORMANCE OF THE WORK FOR WHICH <br />WORKERS' COMPENSATION LAWS OF CALIFOF <br />THAT IN THE PERFORMANCE OF THE WORK FO <br />OF CALIFORNIA" <br />Appllcanrs Signature <br />PA Site # _ I Project Contact & Telephone # f)1 M Wj-�j U �C)Ci 4b 1-� <br />�I Phone ( -,A ,1 <br />I <br />.:1 c, -) Cp o <br />Phone # I <br />Phone # <br />CA Lic # Class <br />98 .t�'l�, VU00 — Work Comp t <br />Expiration Date <br />Expiration Date <br />Tank Size Chemicals Stored Currently Date UST <br />W installed <br />l <br />i <br />„�pproved with conditions ❑ Disapproved <br />(See Attachment With Conditiioonjs)�ijl, A Wk <br />% /� / <br />4DANCE WITH $AN JOAQUIN COUNTY ORDWNCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />P,,RTMENT. OYNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />RS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />!P." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />IA RICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />BILLING INFORMATION: <br />indicate the responsible party to be bill_ far additional EHD staff time expended beyond permit payment coverage per tank, If <br />the party designated below is differen Shan the permit applicant, e.g- property owner, the party must acknowledge this <br />responsibility for the billing -by signature x date below. ��{{ tt//�(('')) n X [�� �, 2�-y <br />NAME �k�f.0 e M)Tf�RC�(Y� 1.0L ITLLE�bi(xu PHONE# GCJ t(p ut1 , � <br />ADDRESS�Nj UO n X IL'AV �� <br />i' <br />SIGNATURE' `T �{ii1 \�Y�i 1 _ DATE 1 -� - 2Lft. <br />EH230038 (revised 08!1!11) <br />2 I �� <br />0 <br />b'd Z�E9T9tr60ZT 5-1040e4UO3 AI a4T13 d6T:aT t,,T 60 iter <br />