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f , <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 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 /> ❑TANK RETROFIT "PIPING REPAIR/RETROFIT VUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# <br /> A I Project Contact&Telephone# <br /> C Facility Name ,TU tiC Phone# 7� <br /> Address r 2N-12, 3-4 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name ,�n _ <br /> Q �►( / Phone# <br /> TContractor Address , CA Lic <br /> R # <br /> 712e Class <br /> n� <br /> A Insurer U Work Comp# C <br /> T ICC Technician' Name <br /> Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work areacals Stored Current) Date UST <br /> 7TankSize Chemicals(i.e.87 piping sump,91 leak detector,UDC 112,etc.) y Installed <br /> T ( P/ <br /> A <br /> N <br /> K <br /> P L-: Approved pproved with conditions ❑ Disapproved <br /> L (See achment 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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title 40 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 billing by signature and date below. <br /> NAME J L1WC1 1�Ov\ TITLE O WAJepn PHONE# -9a3'L\-71-T <br /> ADDRESS 1 -7 1 1 /� Mn�� .16 y"-,L <br /> SIGNATURE < 4 .t' .^ aDATE 1, <br /> EH230038(revised 10/30/12) <br /> 2 <br />