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t: I i I IRUNWNTAL HEALTH U-WRTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />i f - <br />RETROFIT PIPING REPAIR PERMIT <br />BELOW,THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE <br />0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT '� D UDC REPAIRIRETROFIT 0 COLD STARTIEVIR UPGRADE <br />F <br />EPA Site ()C <br />Project Contact & Telephone # p <br />A <br />G <br />Facility Name <br />Phone <br />I <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />one C <br />C <br />O <br />Contractor Name n <br />Phone # 1-74-7 <br />N <br />Contractor Address 1�1 S ® Vc.® , �o <br />CA Li Class(Ie� <br />R <br />A <br />Insurer %e 13�i yy <br />work comp # Qtf q 7S 5 <br />T <br />ICC Technician's Name C i <br />Expiration Date V/ <br />R <br />ICC Installer's Name M' -lc ce'r" <br />Expiration Date <br />Tank system work area <br />(te. 87 ppwi9 gyp, 99 leak detector,: UDC 9t2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />installed <br />(�� } O', ��� <br />ie e, <br />T <br />A <br />IN <br />7 <br />a✓ <br />P <br />C1 Approved ❑ Approved with conditions ❑ Disapproved <br />: (See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 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 FOR ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A ER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBC CTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br />T IN THE PERFORMANCE OF THE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Title �e Si 4YC Date `' �^ <br />M- IJ <br />OF CALIFORNIA." <br />,Applicant's Signaiuce <br />ADDRESS <br />SH -LING I OR A L <br />arty to b ,; b'slled for additional EHD staff time expended beyond permit payment coverage per tank. If <br />:)w is , Ifferent than the permit applicant, e.g. property, owner; the party must acknowledge this <br />by signature and date below. <br />/ 'TAC -TITLE reSf®e PHONE# ' S5 - If 7 <br />Al CA elyet <br />•�/.,. / "" DATE 73-79- 1 y <br />