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DECEIVED <br /> NOV 2 4 2015 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, Califomia 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING'REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIRIRETRO,FIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> Facility Name Phone# <br /> LAddress <br /> T Cross Street c-i�f�stiLd <br /> 1--,- ._.__ _—... ----_ ___. -__ <br /> Y Owner/Operator - Phone# <br /> ---- - - - ---- <br /> CContractor Name ` _ :� Phone# � .� <br /> N <br /> T Contractor Address �X CA t-ic# a 'Class <br /> R <br /> A Insurer 115\JI Il 554t-�/ Work Comp# Ili("LZ 3`{6 <br /> _ <br /> cICC Technician's Name <br /> T N l Ic Expiration Date S 2( (�— <br /> o <br /> R ICC Installer's Name Expiration Date -7 ?pr <br /> Tank system work area Date UST <br /> (I.o.a7 piping Bump.91 lookdoWtm,UDC W,.1c) Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> Ic <br /> P ❑ Approved b Approved with conditions ❑ Disapproved <br /> I- (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACOORD CE VNTH SAN JOAQUIN COUN ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DE ENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR WHIC IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFO I FACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FO TH RMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAVVS <br /> OF CALIFORNIA." �' { <br /> Applicant's Signature Tille V Date- J "'23-1) <br /> J <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed foradditl nal 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 /> responsibilitt f�o=thbilling <br /> by ignat a and datebelsow.NAME1 L%- ►"'�I �TLE _ `� PHONE# <br /> ADDRESS <br /> SIGNATURE ____PAI-E <br /> EH230038(revised 07-17-2014) '-JV \ <br /> 2 <br />