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- 4 <br /> 4 Z- <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 II G 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# ` �, �<e ��' .�' <br /> A <br /> Facility Name C' Phone# <br /> 1Address '755' <br /> -( Gt <br /> TCross Street <br /> Y Owner/Operator ChVrM PrCldtACAS com4nq Phone# <br /> oContractor Name n� err `nG Phone# <br /> T Contractor Address 30 t G CA Lic# 3003445 - <br /> Class -Z r_P <br /> A Insurerr .5vr Work Comp# p�® `� �� 7� <br /> T ICC Technician's Name l(lick H4rvt 511513 9 Expiration Date 01 /2-5/20115 <br /> RICC Installer's Name 1'c Expiration Date 1 <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 /> N /! <br /> K t4 C Od <br /> 64 dC <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A C� <br /> N Plan Reviewers Name Date `(10 <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 Title C" C.l 9 y It v yrs Date P <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. Cg <br /> NAME TITLE /,,/IG✓�,®�+'����e�WHONE# 7/ < <br /> ADDRESS �s ed s a 41 �vP 1 ✓ c c La j o C=7Zap -p 5.^may <br /> SIGNATURE DATE <br /> EH230038(revised 08/1/ <br /> 2 <br />