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i <br /> e <br /> 1 <br /> ENVIRONMENTAL HEALTH DEPA LW <br /> SAN JOAQUIN COUNTY 1��D <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 0 9 2014 ' <br /> Telephone: (209)468-3420 Fax: (209) 468-34�33��l1 <br /> APPLICATION FOR UNDERGROUND STORAGE '00NMENTAL HEALTH ' <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 18C DAYS FROM THE A?PROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> E TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br /> f <br /> F EPA Site# Project Contact&Telephone <br /> A Facility Name ol eum I Phone# -893 —Ll�/� <br /> L <br /> Address �h <br /> Cross Street <br /> TyQ -� 99 <br /> Y Ownerloperator Phone <br /> Contractor Name i Phone <br /> o ' <br /> N CA LI # gf 3 Class l <br /> T Contractor Address <br /> A Insurer { Work Comp# �� / <br /> c ICG Technician's Name Expiration Data Vq—�-- 5— <br /> T <br /> 0Expiration Date <br /> R ICC Installer's Name <br /> Tanks tem work area Date UST i I <br /> system Tank Size Chemicals Stored Currently Installed <br /> (i.e.w piping sump,91 leak detector,UDC 1l2,e1C.) 1 <br /> T <br /> A <br /> N <br /> K <br /> P Approved E, Approved with conditions C 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 i <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 NCT 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 INT HE PERFORMANCE OF THE WOR OR WFIICH THS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Appllcanl's Signature <br /> BILLING INFORMATION: <br /> lndicate 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 billing by signature and date below. Q <br /> Nif 7LE L t1YIG1 I� PHONE# V 1-" �� <br /> ADDRESS4(revised <br /> 1 <br /> ��D r <br /> SIGNATUDATE <br /> EH23003817-2014} <br /> 2 <br /> t,Z'd 89689t?860Z uaneiOJled elQeBe�l 890:CO t71 60100 <br />