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ENVIRONMENTAL HEALTH DEPA �ILEfI, ,, <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 0 9 2014 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> rrN�VIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEPARTMEOT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> n TANK RETROFIT ❑PIPING REPAIRIRETROFIT o UDC REPAIRlRETROFIT C COLD STARTIEVR UPGRADE i <br /> F EPA Site# Project Contact i Telephone# a0 -(P0'-1-Q33 b <br /> AA <br /> C Fac lily Name Phone# 0 3 <br /> I Address I — , ftGl. <br /> L <br /> I Cross Street <br /> T p Phone: <br /> Y Owner/O erator <br /> o Contractor Namei Phone# Q -gys O sg i+p <br /> N Contractor Address CA Lic# 0 ?� Class <br /> T <br /> A Insurer Work Comp <br /> T ICC Technician's Name Expiration Date V"1-ZD- 5- i <br /> D ICC Installer's Namesj Expiration Date 1 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currentiy Date UST <br /> (iA.67 piping sump,91 took ceted w,UDC U2,etc.) installed <br /> T 'n ) d �I' r 64060— <br /> 60-5 yl IL <br /> A <br /> N i <br /> K <br /> P E Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name P-yI <br /> � Q � Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FCLLOWING: "I CERTIFY THAT IN j <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 I <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY i <br /> THAT IN THE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicant's Signatwe Tile Die <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If i <br /> the party designated below is different than the permit applicant, e,g. property owner, the party must acknowledge this <br /> responsibility for <br /> thhebilling by signature and date below. (fS rU Q <br /> NAMEUde�I .J � PHONE# I -O �O <br /> ADDRESS I 0 J3�o ' <br /> SIGNATURE DATE ; <br /> EH230C38(revised -17-2014) <br /> 2 <br /> t7'd E9699V960Z wnePled elge1le2j 899:ZO ti 6 60 400 <br />