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s • <br /> ENVIRONMENTAL HEALTH DEPAR <br /> SAN JOAQUIN COUNTY <br /> IVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 31 2014 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANI-NVIRONV'7-I1 AL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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# <br /> a Project Contact&Telephone# <br /> C Facility Name , . Phone# 0)0 &3 <br /> 1 Address <br /> ISWL <br /> I Cross Street <br /> Y Owner/Operator Phone# <br /> C <br /> Contractor Name <br /> N 1� 4. C_ ,a Phone#�Gj <br /> Contractor Address Y. S-"�- L�JJ CA Lic#��s�S-_ <br /> T 0 � Class 14 <br /> R Insurer - 3— <br /> A . Work Comp# <br /> C ICC Technician's Name <br /> T S'Clk:5 r)L 3 j Expiration Date ' --- <br /> R ICC Installers Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,eto) y Installed <br /> T ST b i tf <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L <br /> A 6 (See A Date <br /> chment With Conditions) <br /> N Plan Reviewers Name_40A i <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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION IA." CONTRA TOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA 0 TH WORK WHICH THIS RMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA," <br /> Applicant's Signature Title �t Date (� 2-C �0 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional END 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 Wl�� �� TITLE 1�, PHONE# �3 S 0 C� <br /> ADDRESS c3. Ct tcm &Vd ' CA ,,b 4 <br /> SIGNATOR DATE <br /> EH230038(revised 10130/12) I' <br /> 2 <br />