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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 <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 START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # tV'-03 <br />A'`R� <br />C <br />Facility Name �� CXR t <br />Y -L' ol in.�. <br />Phone #. _. <br />Address <br />mUf1 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operato t <br />Phone # -'401 _ <br />C <br />Contractor Name - - <br />CQE15-)01Phone <br /># - - - - -- — <br />N <br />T <br />Contractor Address <br />CA Lic # Q%(o Class <br />A <br />Insurer — Explow <br />Work Comp # 3 <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />roved with conditions ❑ Disapproved <br />L <br />(See ttac nt With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date 9 /2 h7o l -/-- <br />APPLICANT MUST PERFORM ALL WORK I AC NCE WITH SAN JOA UI LINTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. <br />OWNER OR L ENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br />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 <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFtMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." YY <br />a 6t <br /><it �I/Lz <br />Applicant's <br />SignatureT <br />A I - <br />tle- pate <br />- <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this res onsibility for the billing by Dsignnature and date below. yvI ,/ � j � <br />NAME � � � ► / L J I (L!/ TITLE l �e / ` ` � u( PHONE # 1-4 - 4,&1-6337 <br />AnnRFG.1; <iF INS (ASL t7 �1 '�T7Yl <br />SIGNATU <br />EH230038 (revised 07/22110) <br />E <br />