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ENVIRONMENTAL HEALTH DEPARTMERECEIVE <br />L, <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Califomia 95205 SEP 2 8 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />ENVIRONMENTAL <br />APPLICATION FOR UNDERGROUND STORAGE TANK i rt -s' TrJ �t °^'�TAA�AIT <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS ERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT `PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Project Contact & Telephone # J - `7 1 ,' 3 V <br />V <br />C <br />I <br />Facility Name Phone # <br />-3 t ) 0q•. <br />Address <br />TCross <br />Street <br />Y <br />C <br />Owner/Operator W `}•- Phone # ' <br />Q <br />N <br />Contractor Name -11 LAO 10 -&- I/L t Phone #i� <br />ti PFJ )^7 <br />T <br />Contractor Address (� 2� CA Lic # 1�' �'j Class <br />- <br />AInsurer <br />cICC <br />` �.(� t <br />Work Comp # D-1 u-15 2L l <br />T <br />Technician's Name <br />Expiration Date 5 <br />RICC <br />Installer's Name ��`V`tZ,an �l � <br />Expiration Date 113 - <br />Tank system work area <br />(i.e. 87 Aping Gump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />A <br />N <br />K <br />P ❑ Approved proved with conditions Disapproved <br />L <br />A l With Conditions) <br />N Plan Reviewers Name <br />Date <br />-q A <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 <br />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 <br />THAT IN THE <br />CERTIFY <br />PERFORM OF THE ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Asv*re / ritlo' L1 i�� 1 i� l jli /1. '?� i�/,31t e _ �'-7 <br />pplicartt s c <br />KZXf r-- uate L v <br />r <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 and date below. <br />NAME r Y V '(� �' ` TITLE_ c �/J%AA <br />�( - PHONE # r / l (ice ✓-1 ! " �� �.1 <br />ADDRESS V I ✓� V V . J!� V"- _ C,,,4- <br />- <br />SIGNATURE DATE <br />EH230038 trevis4l 10/3 <br />