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ENVIRONMENTAL HEALTH DEPARTjhf <br /> ED <br /> SAN JOAQUIN COUNTY � N <br /> 1868 E. Hazelton Ave., Stockton, California 95205 A I� <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 y�.TAL <br /> t a . <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 /> D TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan 209-461-6337 <br /> A Facility Name Har s One Stop Phone# 209-471-8047 <br /> I Address 1151 W Louise Ave Manteca Ca 95336 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Hari Kambo' Phone# 209-471-8047 <br /> o Contractor Name Phone# 209-461-6337 <br /> N Contractor AddressAl CA Lic#1001331 Class <br /> A-HAZ <br /> T 25351 , <br /> R Insurer Work Comp# <br /> A <br /> TICC Technician's Name Expiration Date <br /> T <br /> D <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name (�n n f Date �`l/ f)t <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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> ApplicanrsSignature TIUe Office Assistant 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 for the billing by signature and date below. <br /> NAME_A4eaan AAitGhr _ TITLE Off Ce ASS.IStant PHONE#__20R-461- —37 <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 7-26-2016) 2 <br />