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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 DEC 0 4 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK E.NVIRONIIIENTAL HEALTI <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# CiU 2 Sf Project Contact&Telephone# Wi kt t� �s��� Q2�r S�3 "��g <br /> ACc-tMeCPhone#AC <br /> O Facility Name V��� ��! � C".�yr pct <br /> Address /so G14 `y 5-Lc.C. <br /> TCross Street <br /> Y Owner/Operator �G I( �c L�c< f �r� Phone# 5' crg3 ^ S,?,j3 <br /> C Contractor Name Phone# cC) <br /> o /<ty-v', Ccs �ACoers+� �+ 4(D l —(03 - S"r <br /> T Contractor Address Q a cj�, � ' r� CA Lic# I Cr 3 Class /4 HAZ <br /> AInsurer 4� t=om,„ Work Comp# 111373 Ce <br /> T ICC Technician's Name SI��•t►>t�21 Expiration Date //13 1Zc,I� <br /> QICC Installer' N <br /> R Installer's I-V4rK00J Expiration Date 113 1Zc,E�- <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> AQ / <br /> N Plan Reviewers Name ��SGc.� 1`�u`�G' <br /> 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�K FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO/WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." Title 1U/OC. or, Date <br /> Applicant's Signa a1,2q,,7 <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. 1 <br /> NAME IC1II��_��•C �iZ ����tC>��P.�-^ TITLE PHONE# (2-0 Y 9-�-Fr A- <br /> ADDRESS SZ— f�f2rcr• wC' i C k--, <br /> SIGNATU DATE_ 12—IV S <br /> EH230038(revised 7-26-2016) 2 <br />