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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 REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site#C _3 Project Contact&Telephone# <br /> A <br /> G Facility Name <br /> Address <br /> T <br /> Cross Street <br /> Y Owner/Operator �tJ Phone# Z-4__ <br /> (.b <br /> ° Contractor Name L �_c1O Phone <br /> # <br /> N <br /> T Contractor Address CA Lic#`�� Class p�tC` tj� <br /> $7 r`� <br /> R Insurer q y <br /> A veylL,Q� Work Comp# 9 1JV7 <br /> cICC Technician's Name O l� ,, <br /> T � Expiration Date; <br /> ° ICC Installer's Name r`7 <br /> _R Expiration Date 1 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak delector,UDC 1r2,etc.) y Installed <br /> T <br /> N <br /> K. 201 <br /> HEATH <br /> P U ApprovedApproved with conditions Disapproved <br /> L Ix <br /> A (See Attachment With Conditions) <br /> 1 {' <br /> N Plan Reviewers Name j) 1cu Date t � <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 WOR FOR WHICH THIS PERMIT IS ISSUED,t SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LA OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA OF HE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." f iG <br /> Applicant's Signature_ /Tithe L-6 Se"I C-xf S Dale A17-4 <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 h(,e� billin by signature and date below. ^� <br /> NAME TITLE PHONE# I <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 7-26-2016) 2 <br />