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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 REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# q.I/ -337-p So <br /> A <br /> G Facility Name 7-11 O z� Z Phone if <br /> 1 Address !�6 Z <br /> L <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator 7.�/ HC Phone#7/ ^ 41e,9z <br /> o Contractor Name Phone# „ 337-570 94) <br /> T Contractor Address 2,5,97/ CA Lic# 7 Class Z <br /> AInsurer Work Comp# S' <br /> c ICC Technician's Name Expiration Date <br /> T <br /> R <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p(i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T O 7 .5?? 424"lop <br /> LL �� �l /fid+ (��✓� <br /> A / sT �� / sG/100". <br /> N <br /> K <br /> _ pproved with conditions Disapproved <br /> P El Approved <br /> L (SeeAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WO 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�,TOEYV0,RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature 0 Title Aulez AmWeA69- ate <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. tn�/� <br /> NAM- / TITL� '' �1 /1PHONE# �T/'�37 <br /> ADDRESS Z3--Fv C axq! 4k�� <br /> SIGNATURE DATE �t Z <br /> EH230038(revised /11) <br /> 2 <br />