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S oL OF <br />ENVIRONMENTAL LTH DEPARTMENT" <br />SAN JOAQUIN CO <br />1868 E. Hazelton Ave., Stockton, California 95205 MAY 05 2016 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT R PIPING PAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />O TANK RETROFIT ® PIPING REPAIRtRETROFIT C UDC REPAIR/RETROPIT D COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # <br />APhone <br />C <br /># <br />Facility Name 1, t 1 ' <br />1 <br />L <br />Address <br />i <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # <br />C, <br />0 <br />Contractor N ame <br />Phone L ' <br /># <br />N <br />Contractor Address � j , �+" P CA Lic # <br />R <br />A <br />Insurer. <br />Work Comp # <br />QICC <br />T <br />Technioian's Name,(Expiration <br />Date <br />0 <br />R <br />ICC Installer's Name g` Expiration Date <br />Tank aystem work area Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />l,.e.67W� P.9118akdaedar.UOCu2.�J <br />A <br />K <br />P <br />❑ Approved `19,,Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A.,t <br />N <br />Plan Reviewers Name L " d'_ j a 1 $ �.. Date " r <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY. ENVIRON ALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />WORK FO WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />THE PERFORMANCE OF T <br />WORKER'S COMPENS ON LAWS OF CALIFORNIA." CO ' R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />THAT IN THE PERFO NCE OF TH RK FO tCFT NIS PERMIT IS ISSUED, I SHALL LOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" <br />AppBc, -Signature; <br />i <br />v <br />BILLING INFORMATION: <br />Indicate the respbt�sible, , a y e billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the patty des$naterT 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 />NARAE E TITLE, , <br />i —� ' - <br />SIGNATURE <br />EH230036 (revised 1 <br />Loch <br />