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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <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 /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE G <br /> F EPA Site# Project Contact&Telephone�Phone <br /> 1�t.v�t 1,A Facility Name " pp� z. kC/0 3�I <br /> Address i a c o ,t:c WL-W we- Seo CVAOLt <br /> I Cross Street <br /> T Phone# tTff <br /> Y Owner/Operator &kjto i <br /> C Contractor Name A.6 (,I Ott G�f G T c t-�-- Phone# <br /> N ` _ Ld-� C-I}' ClaSs'V,Aj CLd Contractor Address `" t ? L0 CA Lic# <br /> R SUS VouA_ Work Comp <br /> A Insurer �� <br /> cICC Technician's Name Ir'�.it Expiration <br /> T -- <br /> R ICC Installer's Name Expiration Date <br /> Tanks stem work area Date UST <br /> y Tank Size Chemicals Stored Currently Installed <br /> (Le.67 piping sump,91 leak detector,UDC 112,eta) <br /> T <br /> A z <br /> N I t <br /> K i <br /> tJ <br /> P ❑ Approved Approved with conditions ElDisapproved <br /> L (Se4 Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date—..F – q Cj 171 <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: "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" ,r a, /-� ` *Z`>� ZZ <br /> Applicant's Signature ` Datb. � <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 tihe� li <br /> billing by signature and <br /> �date <br /> �below. �j�ry� Q <br /> NAME ' ^' `r �S�� rT7�J TITLEIrO{{,( �((�t(�L2 �L�GI'_PHONE# c."- 'c . 7: 0 <br /> ADDRESS <br /> (� �'� �. <br /> DATE <br /> SIGNATURE ll * <br /> EH230038(revised 7-26-2016) 2 <br />