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ENVIRONMENTAL HEALTH DEPART,� <br />SAN JOAQUIN COUNTY EIV <br />1868 E. Hazelton Ave., Stockton, California 95205 DEC 0 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 5 2014 <br />APPLICATION FOR UNDERGROUND STORAGE TAN VIRONMENTAL <br />RETROFIT OR PIPING REPAIR PERMIT �EpAITIV►E�EA�TH <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />BILLING <br />EPA Site # <br />Project Contact & Telephone # .,� ;5 C <br />C <br />Facility Name CL -5717rlow <br />Phone # .. <br />_ <br />L <br />Address _ <br />TCross <br />Street <br />Y <br />Owner/Operator �` <br />Phone # c .y c Kc-, - <br />C <br />Contractor Name <br />Phone # <br />N <br />T <br />R <br />Contractor Address <br />CA Lic # % LG C` Class C - 'G <br />A <br />cICC <br />Insurer <br />Work Comp # � C� <br />T . <br />Technician's Name S <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system worts area <br />(i.e. 87 piping sump, 91 leak tleteci:,f, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions Disapproved <br />A <br />N <br />(�4 T7A chment With Conditions) <br />Plan Reviewers NamjL. <br />1 MkE) - 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 I:L."LTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE '1 <br />FOLLOWING: CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR','. HICH 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 C:-.LIFORNIA." 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 '>W -Al' _Z2 Title i!�/ C A-6, 5i---30)49- <br />t.-_J0iSL <br />BILLING INFORMATION: <br />Indicate the responsible party to h, a billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is c.ferent than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by sign .-. ure and date below. <br />NAME //s �_ ��'E f dC �. L TITLE �`L (- i'�y- PHONE #_20? 3 k'4 <br />ADDRESS V� �4!�S' <br />SIGNATUR�-1i� 7t,yG� c' SIC-yti- <br />EH230038 (revised 10/30/12) <br />2 <br />