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0 <br />9 <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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # am KOS4 201 ' <br />A <br />C <br />Facility Name <br />ho <br />Pne # <br />I <br />L <br />Address <br />I <br />Cross Street <br />TPhone <br />Y <br />Owner/Operator d� ' <br /># p ' <br />C <br />Contractor Name um <br />Phone # a 3-3e�O <br />N <br />T <br />Contractor Address ,� , Class <br />A <br />Insurer <br />Work Comp # <br />TICC <br />Technician's Name44;qid," WA SS <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />A <br />N <br />f, <br />K <br />NV 17 2014 <br />ENVIRONMENT <br />P <br />AFL(�IHEALTH <br />El�s�p <br />Approved Approved with conditions DprM "T <br />L <br />(SeKA tachment With Conditions) <br />A <br />N <br />Plan Reviewers Name&uva-- mu,2 A-) 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 TE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." Xr <br />—�/%Annlica nt's Rinnature- / ! /1 0 V Title � (Qm� 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 TITLE PHONE # <br />ADDRESS <br />SIGNA <br />EH230038 (revised 07-17-2014) <br />M <br />f� <br />'36/fIXL <br />