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ENVIRONMENTAL HEALTH (DEPARTMENT <br /> SAN JOAQUIN COUNTY RiEcjEjv,�.,) <br /> 1868 E. Hazelton Ave,, Stockton, California 95205I <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> Ax dU1� <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 1�NV/ROWEV, y <br /> RETROFIT OR PIPING REPAIR PERMIT PERM1Tis � �a IN <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> 1 <br /> F EPA Site# Project Contact&�Telephone# <br /> Facility Name L� yy e �1L !7 Lf�p Phone# <br /> Address lqt03C Oiki t, fU + C 6 %, C7Ul <br /> T <br /> Cross Street <br /> Y Owner/Operator 01:1414 CCS' 6 lr �c Phone# <br /> o Contractor Name rme)pr 1e rd I,eool r✓fc,e Phone# <br /> T Contractor Addressa 4eO &rn" 14H` 0 ISI C Llc# # 'q997class 1+s GID <br /> A Insurer J4-41C. Com � Work Comp# �073S'a tq <br /> T ICC Technician's Name <br /> &Ikr{CrX Vy� Expiration Date ~-( --I 9 <br /> R ICC Installer's Name <br /> Ph}'Y'I LIQ � �{1'r�L3t.JY!" Expiration Date , �-Jb--��' <br /> Tank system work area Tank Size Chemicals Stared Currently Date UST <br /> p.e.87 piping sump,81 teak detector.UDC V2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N CA ` '^1_ <br /> Pian Reviewers Nama Date 1' <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 THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." Q� <br /> Applicant's Signature Title <br /> C r Date —qDQ2KL:1 <br /> p <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 /> NAMEQ ( ''rr '� +,}t" TITLE Y�'P - PHONE#___ <br /> ADDRESS i- '�' X tDe>-7 Cf6 <br /> SIGNATURE DATE_ F Fes" <br /> EH230038(revised 12-11-15) ~2 6 IP 1-7 <br />