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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 />D TANK RETROFIT )(PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # TC <br />� <br />Facility Name"T—pIt CX 77C1 Q +Q Phone # 2 C)10 <br />Address cj 1 c Lei �Y <br />TCross <br />StreetW F c7— U <br />Y <br />Owner/Operator ' Phone # Z Oct %'2-55 t7C� <br />Contractor Name ' <br />i` � Phone # q I ttf� G2 i.i 9 JS5 <br />C <br />Q <br />N <br />T <br />Contractor Address ' %(� e CA Lic # 1'-I"'j 9 Z Class ,4 i3,( -,,4A22 <br />A <br />_ <br />Insurer l Qat e 2R e +l g s Work Comp#UBrsZ35X • i1L1 <br />C <br />T <br />ICC Technician's Name i <br />HJT Q' Expiration Date -a <br />R <br />ICC Installer's Name I' (r. U Ij Expiration Date to - Z 3 - �v <br />Tank system work area Tank Size Chemicals Stored Current) Date UST <br />0.e. 87 piping sump, 91 teak detector. UDC 112, etc.) y Installed <br />T <br />tf---^\\ JCI lE <br />A <br />N <br />K <br />P <br />❑ ApprovedApproved With conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date ("T , <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: '1 CERTIFY THAT IN <br />E 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 CAUFORNI .' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />THAT IN THE PERFORMANCE O THE WORK FO RICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title f l OR Date r `7 <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 />responsibilityfog a billin' by signature and date below. <br />NAME//V% / C�'/2�/ TITLEi1Q/�i//�Uf� PHONE # <br />2 <br />