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t <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fag: (209)468-3433 <br /> APPLICATION STORAGE TANK RETROFIT OR PIPINGPAI IT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# J O <br /> C Facility Name ) S Phone „� ® — <br /> L AddressCAA�14S <br /> TCross Street <br /> Y Owner/Operator ZA- Ul A) ` P0t` <br /> c Contractor Name G , hone <br /> 0 <br /> T Contractor Address / CA Lic ?'-7 Class .Cb/. ® <br /> A Insurer ”' Work Comp# pi&j 00Cqr 10 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name VSg f3 UM190 Expiration Date dID <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detector,UDC 1/2,etc.) Installed <br /> T , S <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Na Date /LJ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO ANCE 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." Ey04Tgrepa=f <br /> Applicants SignetTitle Date Z&& <br /> BILLING INFORMATION: <br /> Indicate the risible 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. pr6perty owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. G� /^ <br /> NAME ?� TITLE &ES r �[s PHONE# q) 367-41M <br /> ADDRESS ,3 �h L L� tO I <br /> SIGNATURE DATE T <br /> EH230038(revised 02/20/09) <br /> 1 <br />