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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 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # 'vlT`�� <br />A <br />Facility Name # <br />Oz lq� t/k/0 '7 20"7 -i�C7 <br />� <br />,v�f/J /Phone <br />Address o� J -7 J C /� <br />I <br />T <br />Cross Street P� f�/�_K <br />Y <br />Owner/Operator 6,11-(t r1i f et iii e l S q <br />Phone # <br />o <br />O <br />Contractor Name Ce- �� �r l.eu O <br />t�/'1tY� Phone # GjZ.S = /�� Z6 <br />T <br />Contractor Address 7 A Lic # Class �� D <br />R <br />A <br />IInsurer S1 e r4�d <br />Work Comp # `7 -A tV;1,33-2,-j • <br />cICC <br />T <br />Technicians Name <br />'.JoSe /i •SGGte- <br />Expiration Date 1 <br />R <br />R <br />ICC Installers Name <br />' Expiration Date <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 <br />A <br />N <br />K <br />i <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />r j$ee Attachment With Conditions) <br />N <br />Plan Reviewers Name i <br />Date <br />I <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 /�'�y=/�it /-7/1 <br />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 <br />orr the billing by signature and date below. {� <br />NAME 6A1.Z!? � /7 J/Z�,Z4- TITLE "' PHONE # 12 S �� Z ` <br />ADDRESS S�c,� 2-7 �. Gi <br />SIGNATUR <br />EH230038 (revised 10/30/12) <br />2 <br />