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ENVIRONMENTAL HEALTH DEPA <br /> IVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 SEP 0 8 2014 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 FFNN <br /> APPLICATION FOR UNDERGROUND STORAGE TAWRGNMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT OERARTMENT <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 EPA Site# Project Contact&Telephone#GQA, _, : . 1 <br /> A r <br /> G Facility Name 1 t -- � �� 'Z � Phone# 1%, <br /> I Address <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator t`Gtv� Phone# D'o 11_ _ Cot, <br /> o Contractor Name C_ Phone# <br /> 0 <br /> N Contractor Address i , CA Lic# .11 'r�� Class A-- �Z <br /> T C <br /> R <br /> Insurer ` i).i) ��i� Z Work Comp# ((Dq <br /> C <br /> T ICC Technician's Name z0 Expiration Date <br /> RICC Installer's Name GQ��f%4_� �u\2 ciS Expiration pi Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump.91 leak detector,UDC 1/2,etc.) Installed <br /> T ► O Oo iq GAS <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Date <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 the <br /> billing by signature and date below. i //,i �� <br /> NAME G-aN?5 t�` V�� -\�`i TITLE C)'C�el�` �0`(1��G C�O� PHONE# �- l 'Y 7�- f 33tr <br /> ADDRESS [J, N �1 ��(\�-- Vex- ` CA <br /> SIGNATURE ! --- DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />