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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <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 /> ' LTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name / Phone # y� i c�y7 76 i ` <br /> i Address A //ulmireaivoe f6 <br /> TCross Street QIdile <br /> Y Owner/Operator 74 Gvkle Phone # q 5 1/Z 2 76� 5 " y <br /> C Contractor Name ' -� Phone #0 Jinn / 6 Qyc 6w6 <br /> N t <br /> t <br /> Conracor Address <br /> T 0 `>'v'j(1n � (vz CA Lic # + 3N� Class A C P1144 <br /> A Insurer ..� �?� �S �S jtr Work Comp # OC)o • �1 _ / R/ <br /> TICC Technician 's Name k 1J i(VeExpiration Date 0g <br /> ICC Installer's Name Expiration Date <br /> R /(fry l2 /Ovv� p 67Z l-to , c� <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T 1 w .: 3ok° <br /> iA � �lc <br /> K � D (< <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 : "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." � �J (� <br /> Applicant's SignatuTitle 9161 � Jt- I y��'77,( 7 Date <br /> re <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 ��/t�If U�XG�r�"� TITLE r1`C� ) L1yy s PHONE # `9�� ijt✓�d Q `5/6 <br /> ADDRESS ,5'0 Ale V , e PC V'FJva+ " ( A qS' " <br /> SIGNATURE � � DATE � � - Z0 / `� <br /> " H230038 (revis 0130/12) <br /> E <br /> i <br /> i 2 <br /> z <br />