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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 '❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COW START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone #��k <br />him tq)lu <br />C <br />Facility Name <br />Phone# I <br />I <br />L <br />Address <br />6 <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />mg <br />C <br />0 <br />Contractor NameEUTET7"— <br />Phone # - <br />TContractor <br />Address <br />CA Lic # �Il Class <br />u <br />PAZ <br />R <br />A <br />Insurery _ e <br />Work Comp # cJ <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1l2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />L <br />❑ Approved Approved with conditions ❑ Disapproved <br />A <br />y. - See chment- With Conditions) <br />N <br />Plan Reviewers Nam <br />Date_ <br />APPLICANT MUST PERFORM ALL W K IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMEN L HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE' CERTIFIES <br />THE FOLLOWING: "I CERTIFY THAT. IN <br />THE PERFORMANCE OF THE WO K 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 <br />THE FS)LLOWING: "'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 />i <br />Applicant's Signature LNks Till. iAo f1ro. —L 1iP 1 n c. t 0/? nA IA <br />s <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 <br />7for the billing by Signature! and <br />cdate below. <br />NAME C l�� C �T�`� � 7 (& o ITL E Q �r� � 0 PHONE # 2,CUS <br />ADDRESS 2;z__�'5yy(�11(yt1�1�_�Q� sic1��,-��1, ca,, <br />SIGNATI IRE——l��� iLW�J DATE_ <br />EH?_30038 (revised 07-17-2014) <br />2 <br />