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r w <br /> ENVIRONMENTAL H ALTDEPARTMENT <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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name © 2_&®2 Phone# __26 p g3,j�— ? 7 7 <br /> Address X3® U o � ` 7� <br /> TCEoss Street <br /> Y Owner/Operator fit' Phone# 20 936,F7 7 7 <br /> C Contractor Name k— -Ge-L l.) S-eilVize_s The • Phone ap�f_irys-gs-e l <br /> N Contractor Address �) D eShoe- CA Lic# ���-10 Class,+ <br /> T <br /> A Insurer Work Comp# 3-36blf 2-66F <br /> T ICC Technician's Name C V� ,d t, ta-e 54ptC_Jq-C_Z Expiration Date ®Y—Z 3--/3 <br /> RICC Installers Name <br /> R ' (�' t,tp•-2 csav� .L—L_ Expiration Date J,2 - <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) y Installed <br /> T 79 <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date CK2 3 (-L <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 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 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 Date <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 <br /> cfor <br /> �the billin by signature and date below. �^ t <br /> NAME a u fll e &blf,"m J�rV, TITLE C (}c�1.�71ru�)� PHONE# 0 <br /> ADDRESS f 3® 1rj� t't�'(, d wf (JAL. ! 0 / <br /> SIGNATURE � �.-.. DATE <br /> EH230038(revised 08/1/11) <br />