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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQ,UIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 i <br /> APPLICATION FOR UNDERGROUND STORAGE.TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> t <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE 9 PROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Q j4 Z IQXS $Sq 6$'9,2 g,7-7 X <br /> C Facility Name � � F Phone# �� <br /> L <br /> Address <br /> Al <br /> I Cross Street <br /> T <br /> Y Owner/Operator ( Phone# ?Da <br /> C Contractor Name �' Phone# ��') yG�D2_ 1 <br /> O <br /> N Contractor Address 110C) 41 �T -P, 9 A Lic# 5D41 IJ" Class .R c <br /> T <br /> R Insurer Work Comp# <br /> A <br /> a T ICC Technician's Name <br /> Expiration Date <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,uoc ire,eta) Installed <br /> TWX5141 9 <br /> N <br /> K <br /> P ElApproved Approved with conditions ElDisapproved <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 <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 PER ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu —Date_ --- <br /> BILLING INFORMATION: <br /> Indicate the r le arty to be billed for additional END staff time expended beyond permit payment coverage per tank. If <br /> the party design ed low is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibilliityy for tthe filling by signature and date below. <br /> NAME' � -6S\ 511 si1L� QL.d��TITLE�Iux=C��151 � _PHONE#_ 2Vcl �� l rD4LQ <br /> ADDRESSA __ — <br /> SIGNATURE_____— _ —_—_DATE _ <br /> EH230038(revised 10/30/12) <br /> 2 <br />