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e_is ,N , r Niyl ryy� .� yS �� ry , 1 . yr . yy yi ► y-, a <br /> # 1 P'r 1 lip 7 N�; N�tl1'r..j� <br /> 11 <br /> 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 4S 600 East Mafn Street, Stockton, California 95202 <br /> Telephone. (209)468-3420 rax: 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 11 PIPING-REPAIR/RETRO FIT 11 UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ( <br /> (A <br /> c Facility Name n,I cPhone# r <br /> L Address Z 2. -'IT <br /> w l <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> 0 Contractor Name <br /> ° Phone# <br /> N Contractor Address <br /> T CA Lic# n Class <br /> AInsurer <br /> d Work Comp# <br /> cICC Technician's Name <br /> T <br /> ° Expiration Date <br /> JCC Installers Name <br /> R ' _ Expiration Date <br /> Tank system work area Date UST <br /> (.e.87piping sump,g1leak detector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> pp El Disapproved <br /> P El Approved , roved with conditions <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Na �- ""� � ,/a ��i�ii <br /> Date XJG_ :2�-% <br /> APPLICANT MUST PERFORM AL ORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRON NTAL 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&MANNER-AS.TO BECOME.SUBJEOT.TO <br /> WORKER'S-COMPENSATION LAWS OF CALIFORNIA CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT LI FORNIA THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> OF CALIISSUED,I SHALL EMPLOY PERSO.N,9 SUBJECT TQ.WORKER_S COMPENSATION LAWS . .. <br /> <:._.., <br /> Applicant's Signature Title <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 /> _. <br /> -NAME E.1 Il'E.III C c1'C1T�R1� T(YL',s1 $h i��mt�t41� Y, <br /> _PHONE#__2(n <br /> 7 <br /> UAJ <br /> SIGNATURE-- <br /> EH230038(revised 08/1111) <br />