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1 <br /> ENVIRONMENTAL HEALTH DEPART <br /> SAN JOAQUIN COUNTY WffiEIVED <br /> 1868 E. Hazelton Ave., Stockton, Califomia 95205 MAR 18 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: 4'"w <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE )v p1:V?,C5,01r <br /> F EPA Site# Project Contact&Telephone# � 1�Q� 00 <br /> A <br /> D Facility Name r.2 f6" � 5r-1-0,P Phone# <br /> Address �� <br /> TCross Street <br /> Y Owner/Operator �'n f�JTL Phone# t`t,� _ ► <br /> C Contractor Name <br /> * . Phone#lW , _ <br /> T Contractor Address QO 2),—y CA Lic# <br /> Class - <br /> R Insurer <br /> A Work Comp#1073C) �- <br /> T ICC Technician's Name <br /> Expiration Date <br /> R ICC Installer's Name AMV.Q /�� „ <br /> G(l�.��v t�Ei'� \7E�w j Expiration Date i 7 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Aprroved Approved with conditions ❑ Disapproved <br /> L <br /> A (AAachment With Conditions) <br /> N Plan Reviewers Name <br /> 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: "1 CERTIFY <br /> THAT IN THE PERFOPqMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's p— <br /> 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 , TITLE PHONE# 2001 SS'32 SaC: <br /> ADDRESS' WO IN �� (q YL� c <br /> SIGNATURE '� _7 DATE 5 12-J <br /> EH230038(revised 07-17-2014) <br /> 2 <br />