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ENVIRONMENTAL HEALTH CEPAE + ` � <br /> RTM <br /> SAN JOAQUIN, COUNTY SEP 1 Y 2014. <br /> 1868 E. Hazelton Ave,, Stockton, California 95205ENV1R0NtM EIS-'i,4A1_ t <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 HEALTH <br /> DERAR TMEENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THI$PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INdICATE PERMIT TYPE BELOW_ <br /> TANK RETPOFIT 0 PIPING REPAIRIRETROFIT a UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F F-PA Site# Project Contact&,Telephone# <br /> A <br /> G Facility Name 111ji.111111C _ c Phone# <br /> Address <br /> L 6 ( +� <br /> TCross Street _ <br /> y OwnerlOperator�7 � <br /> c �`t3ii�... Phone# c�et_ <br /> a Contractor NamTMe <br /> N Contractor Address <br /> ? ` t CA Lic# <br /> R 1-11 QU �1 Class A <br /> R Insurer <br /> A <br /> CICC Technician's Name <br /> T (x'4�r t Zj v Qty �,S Expiration Date <br /> ]CC Installer's Nae1 ' <br /> Rmt aJf Expiration Date I- <br /> Tank system work area Tank Size Chemicals Stored Currently pate US7 <br /> (i.e.a]pi�aump, i leak deteoior,ucc m,etc.) h Yy Installed <br /> T it a Qy t7 <br /> A <br /> N <br /> K <br /> P C Approved pproved with conditions Disapproved <br /> A (See Attachment With Conditions) <br /> N Flan Reviewers Narne <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ONDINANCES,.STAT[LAWS,AND RUL53 AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNG; "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME 5UBJEC7 TO <br /> WORKE*S COMPENSATION LAW$OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK R WHICH THIS PFRMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S CONIP�N$ATION LAWS <br /> OF CALIFORNIA." f 1 J <br /> Applicant's SlgnatureTitle <<srti (.gAtXq(+}p� Dote <br /> BILLING INFORMATION: <br /> Indicate the responsible pally 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 forthebilling by signature and date below. Ii <br /> NAME f'�� \ �1 C44 rITLF cJNIPSO 1 l oJ) - 'J pt40NE a� <br /> ADDRESS <br /> SIGNATURE__2 f DATE <br /> EH23003B(revised 07-17-2014) <br /> 2 <br />