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0 0 <br /> ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Tele hone# q5-7 <br /> A 1 p flbb ` {�ma�✓ y�7- <br /> Facility Name Phone#.:7 <br /> L Address Hellr YY'1 4 61&ckionCA 952iD-3 <br /> TCross Street <br /> Y Owner/Operator p Phone# <br /> C Contractor Name moorRcIeom ,n1`Ce Ia M4,0,p ep.rp Phone# <br /> N Contractor Address C CA Lic# Class <br /> A Insurer E y-,e ► I TnS ,, Work Comp <br /> C <br /> ICC Technician's Name <br /> T Acmbur Expiration Date -7 r,Z -,;?C% 13 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> i.e.87 piping sump.91 leak detector,UDC 1/2.etc.) Installed <br /> T P r 'M <br /> A <br /> N <br /> K <br /> P i Approved Approved with conditions Disapproved <br /> L (Se c ent With Conditions) <br /> A I, <br /> N 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 <br /> TO 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 Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME -TITLE ]�G e tC�� -PHONE# <br /> ADDRESS L5• 6`' 1 a <br /> SIGNATURE DATE <br /> EH230038(revised 07/22/10) <br /> 2 <br />