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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 />r� TANK RETROFIT ❑ PIPING REPAIR/RETROFIT AUDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # C A P6C1Q / L S Z A <br />Project Contact & Telephone # <br />� <br />Facility Name C /lav}L�,a �% 9, / 7 j <br />Phone # `%LS- yz ' 1l C <br />� <br />Address �-- 3 P1464((- Aug <br />T <br />Cross Street 61� 1 i6 LT 1� , <br />Y <br />Owner/Operator /��dL' DrJ G v <br />Phone # SLS" yL- I acs $ <br />oContractor <br />Name foA joi2 r2 y <br />Phone # 74 C' <br />N <br />T <br />Contractor Address + <br />�C7 /�11j i✓t/ /� U� S c / �>� .� <br />Class H' Z <br />CA Lic # 3ca�' S y� c. Ll <br />RInsurer <br />A <br />,15;�01z/W Z <br />Work Comp #,/)C / y 72-? 2 <br />C <br />T <br />ICC Technician's Name 1 <br />,J �A L 6 H ,,o <br />Expiration Date <br />0 <br />R <br />ICC Installer's Name [-)U,,) SAuz- 44A% <br />Expiration Date LJ -%y-16 <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />') -1 <br />in K 1 <br />6&04, -1 <br />A <br />N <br />o �C <br />G4',n La � <br />K <br />9 1 <br />o K <br />64-5:0 L, <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <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 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />z1V Ki- 4- Al Date / <br />Applicant's Signature Title (� <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 TITLE PHONE # <br />ADDRESS <br />SIGNATU <br />EH230038 (revised 10/30/12) <br />