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12/15/2015 11:19 2094GO SJC EHD UNIT 3 PAGE 01/02 <br /> ■ <br /> ENVIRONMENTAL HEALTH DEPARTMENT.. , <br /> SAN JOAQUIN COUNTY . <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 2 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-34334VA 3j, <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES iso DAYS FROM THE APPROVAL GATE INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFFF D PIPING REPAIRIRETROPIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Phone# Gc�� -�p - Z? �(Q <br /> C Facility Nome Y S <br /> I <br /> L Address - W . II-11t t14 <br /> Cross Street <br /> Y Owner/Operator Zt lffyPhone# 09 ��77- 6000 <br /> C Contractor Name U C—S Phone# <br /> N Contractor Address �� CA LIc#`'� �� Class <br /> T <br /> R insurer work Comp# <br /> A - <br /> c ICC Technician's Name e'ci f lF�Cr y S Expiration Date Q <br /> T <br /> R ICC Installer's Name % v 'll Expiration Date I� ()(6, <br /> Tanks stem work area Date UST <br /> Y Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 dpin9 sump,91 leak detector,UDC 112,etc) <br /> CC)ILLT <br /> A <br /> N . <br /> V.GaI N rlI=DAr_+TAAcRIT <br /> p ❑ Approved pproved with conditions Eloisapproved <br /> L (S�Attachment Wth Conditions) <br /> A <br /> N Plan Reviewers Name 1k i1�> 11'���Y� :J Dot <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 UCENSEO AGENTS 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 SUOJECT To <br /> W'ORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OFTHEWORK FO IGH THIS PERMIT IS ISSUED,!SHALL EMPLOY PERSONS SUBJECT TO WORKER'5 COMPEN5ATION LAvvS- <br /> OF CALIFORNIA" <br /> A lioent'■S;Onstum Tate 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 billin by signature and date below. <br /> NAME TITLE PHONE# � <br /> ADDRESS '�' --- eIn <br /> SIGNATURE DATEE tJ <br /> `'� <br /> EH230038(revised 07- -2014) Ji <br />