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From:ER VINE 209 541 1694 03/10/2015 08:14 #058 P.002/006 <br /> i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY VEL <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 MAR 10 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TANjQI/IR�}NMEIVTAi.� <br /> RETROFIT OR PIPING REPAIR PERMIT "v; <br /> THIS PE�RMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ; PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT [I COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone pU*4(-� R0q-,53 7 g 9t, <br /> Facility Name Phone# <br /> Address <br /> I Cross Street (ftp <br /> T ' <br /> Y Owned0perator Fc)�`T&,TT Phone# _ S <br /> c Contractor Name (,rc� �i] Phone <br /> 0 <br /> T Contractor Address A Lic# Q S Class 6t t(73 <br /> RInsurery�( , of= ~{(�E (� Work Comp#(,J� C3 <br /> A <br /> c <br /> T ICC Technician's Name M 16 V F L Z AXZQ Q-,,q>Z A Expiration Date 5 _ <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T P o f <br /> A <br /> N <br /> K <br /> P E] Approved Approved with conditions U Disapproved <br /> L (Se Attachment With Conditions) <br /> A r��n <br /> N Plan Reviewers Name ��_Mum Date D—01i <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 PERFORMANCE OF THE WORK FOR HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicant's Signature Ile Date <br /> BILLING INFORMATION-- <br /> Indicate the responsible party to be billed for additional EHD staff time expanded 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 by signature aanndd date below. o <br /> NAME L� {Ylf� . __,.TITLE -rCZ[ICA ICA-t3PHONE# <br /> ADDRESS <br /> SIGNATURE " DATE f1 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />