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ENVIRON ENTAL HEALTH DVARTMENT <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 EPA Site# Project Contact&Telephone# <br /> A <br /> G Facility Name Sir �er h¢ f{ ��. �1 q n C� Phone# 2 01 97-:r- 3700 <br /> L Address (^1-7 W. YO se Avg -YY)0i fit'Co, (A R j 3 33 <br /> I Cross Street <br /> T <br /> Y Owner/Operator v-air EI t1ePr%Lw Phone# 20q- 9Z„- 3700 <br /> C Contractor Name Cay Phone# qo _ �� a I <br /> 0 <br /> T Contractor Address I, j M 0y%1&y 1J "46-0 Cm,n CA Lic# 7 37 Class A" <br /> A Insurer ��1� , Ulnolslrwru r-� Work Comp# q(_8(� L-ol_Oj <br /> TICC Technician's Name r\ oyvv\-a Y-\ Expiration Date 2.-2�_ 7 <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 712,etc.) Installed <br /> T C ellirfd Q h+ s T e 12� 41060 'iJ e fie, k <br /> A <br /> N <br /> K <br /> P ❑ Approved VlApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name dena a s r1 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 AGENTS 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 F WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." n I �y/� <br /> Applicant's Signat Title Nye.-,i 1. Date 7.ZZ1 J <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. rr <br /> NAME WqLjY`4 TITLE l(/11 0.t UY PHONE# 901- Z42rZ0fI <br /> ADDRESS t7lS h'1OVAT Sgr\J CA <br /> SIGNATU DATE 7o.26113 <br /> EH230038(revised 10/30/12) <br /> 2 <br />