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a <br />ENVIRONMENTAL HEALTH DEPM <br />SAN JOAQUIN COUNTY L <br />1868 E, Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 458-3420 Fax: (209) 468-3433 MAZ 0 2015 <br />APPLICATION FOR UNDERGROUND STORAGE FANI%NMENTA! . <br />RETROFIT OR PIPING REPAIR PERMIT <br />Q TANK RETROFIT <br />THIS <br />EI PIPING REPAINIREE00 TROFITTHO UDO REP'AIFURIETR Fly' Rp COLD STARVIEVIR UPGRADjE <br />F <br />Site # <br />A— <br />- <br />ame, <br />rAddress <br />L <br />/0 <br />T <br />reet <br />Y <br />Owner/Operator <br />0 <br />Contractor Name <br />N <br />r <br />Contractor Addrass <br />AlnSUrer <br />T <br />T <br />ICC Technician's Name <br />R <br />ICC Installer's Nance <br />T <br />A <br />N <br />K <br />project Canted & Telephone # <br />OKt Me' dk- <br />l3 <br />cl/v Z-6— A/' <br />Tank system work area <br />0.9. W *ng aomp, 91 Iesk datw", UpG 1P2, ate ) <br />e/f <br />Tank Size <br />Phone # Vac,'. Fly--. <br />zre— C, /- <br />phone # <br />Phone # <br />n <br />Class <br />Work Comp # <br />ExpimtIon Date <br />Expiration date <br />ChemiCal5 Stored Currently Date UST <br />Installed <br />Approvesd � AApproved with conditions Disapproved <br />(See Attachment With Conditions) / <br />NJ n Reviewers Name d �i <br />Date <br />3PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />UIQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE: FOLLOWING: "I CERTIFY THAT IN <br />fE PERFORMANCE OF THE WORK I70R WHICH THIS PERMIT IS ISSUED, i SHALL. NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />OkKEWS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />IAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA." <br />RliCatlr85igriatute � �*/ Tigg Dale <br />BILLING INFORMATION; <br />Indicate the responsible party to be billed for additional EHD staff, time expended beyond permit payment raverage per tank. If <br />the party designated below is diterant than the permit applicant, e.g. property owner, the party must acknowledge this <br />resportslbiiiiy for th® billing by sigtla6Llre and date below, <br />NAME TiTL� F'HpNE # <br />— -_- " , IV <br />ADDRESS �; <br />SIONATUR <br />. DATE 9 2 015 <br />E17123MO (MVised 0777-2014) <br />c-NVIRON EN!AI <br />,, ,� <br />