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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVE <br /> 1868 E. Hazelton Ave., Stockton, California 95205 D <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 2 8 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK EtMRONUENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMIUSENCES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE ROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT C REPAIRIRETROFIT ,COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A ' Phone# �' %S% tp-11 <br /> D Facility Name 0 N AL C�-v+--S :�� " <br /> I Address {{ ? <br /> L J 7 <br /> T Cross StreetDes <br /> Y Owner/Operator �y.r i r� �� a, f`ywPhone# :5--/d-- l 00 3 j4 a <br /> o Contractor Name 6�4 f;�� Phone# a 0 <br /> N Contractor Address f} 7 &&)I C el <br /> T y .'v L CA Lic# (� ' Class / — dY Z- <br /> R Insurer ✓t rfi N C L R j� '��c,f , ;., Work Comp# k/!-�— V-�.3 r <br /> T ICC Technician's Name p<yyt ,o t, Expiration Date J- /— % 7 <br /> R ICC Installer's NameitAkt 5 Expiration Date i /a._ <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved [P' proved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> p <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CO TY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 (t,�il f r� f Date 10 <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 h I' C I(- PTITLE Q ti�' PHONE# <br /> ADDRESS Z ! 0 rk-IYI 1 I IN I— her' bit f <br /> SIGNATURE DATE <br /> i <br /> EH230038(re sed 12-11-15) 2 <br />