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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 2 8 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK f' <br /> RETROFIT OR PIPING REPAIR PERMIT <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# <br /> A Fa - 2 Vo <br /> O Facility Name y� �i�S Phone# `c7�% -� <br /> � Address r <br /> I Cross Street <br /> T <br /> Y Owner/Operator Ct �� Phone#,;?(19 J 77— 600 <br /> oContractor Name C ^ u ces Phone# <br /> N Contractor Address 3y� ' q iN c CA Lic#`1 Q Z�, ClassAIR. Z <br /> R <br /> A Insurer Work Comp# <br /> C ICC Technician's Name Expiration Date <br /> T Ct,ifFt-��, C1�,�S p� 0ct <br /> ° ICC Installer's Name ��� r j Expiration Date (� L) 010 1 <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 �- m <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 HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS \\\(\\\r]]] lJ1J\ <br /> OF CALIFORNIA." J <br /> Applicant's Signature GG'L Title Date /0 ~ C �0I ✓ O <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 bill' by signature and date below. -7 �` h <br /> NAME Com.\ 1✓ �1>v TITLE 1)V�/y�/�_ - 2 (0 J -f 7� �Q 0 0 ^� <br /> PHONE# <br /> ADDRESS / �)� 6 40 6S_16/ <br /> SIGNATURE DATE�n <br /> EH230038(revised 07-(-2014) <br /> 2 <br />