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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <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 REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone <br /> � Facility Name ,c.I/ Z-0/j ;o Phone# 71- "o!(-71 <br /> 1 Address e,- <br /> TCross Street pry <br /> Y Owner/Operator Phone# 7/ n % �JS <br /> C Contractor Name t ,�G / GCS/,' �/�1 C. Phone# e2l!r ' <br /> C- <br /> N Address CA Lic# O 4 </SClass ;(fl Ul-l7 Z <br /> R Insurer r Work Comp# on 71-2-'7 <br /> A ted' 7 ,�I S. �U <br /> T ICC Technician's Name Cati.� ��� /s''y/�x„$� Expiration Date <br /> R ICC Installer's Name Z�yr /�����," s'Z ��J VZ Expiration Date 1-j- <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T %�i� Seg f SL/�,�J %Z rao c� <br /> K /ci�1�G t✓..n ja /Z c <br /> P ❑ Approved .Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 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." <br /> Applicant's Signature Title �✓ Date <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 /> NAME lif�rq j/7 !i /G✓/ -�h C TITLE CO'-' !'17 f ;O / PHONE# <br /> ADDRESS /YIc,i �► /`fm'lY <br /> SIGNATURE DATE I1- —IZ— <br /> EH230038(revised 08/ <br /> 2 <br />