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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 REPA R 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 # . U �Le- <br /> C Facility Name O (ase Phone # <br /> � <br /> Address 5060 VJ . 6KCJ �411 ✓l P VC1 / ✓G C '75�3 71 <br /> Cross Street <br /> TPhone # L1 5 922 970 <br /> Y Owner/Operator 60g-Fo o e <br /> oContractor Name r Phone # q ) <br /> T Contractor Address 0 � + e j CvLttMa CA Lic # 3003c1 Class A s C Dfimog <br /> A Insurer ✓err- awbonr:< � Work Comp # 37 7Z <br /> or LSA/aD o 3 <br /> T ICC Technician 's Name Expiration Date /�/ /ZoZZ <br /> R ICC Installer's Name IV, ck lldrWtyExpiration Date g13p/292Z <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 ZeApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A �1 k2 <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 : " I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T IS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Sign Title �7G� J �/ X194 S /1 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 / `ArNtr$ S alooeyweo✓ TITLE ���ltri .� itf PHONE # 9/4 6(4 9G &'� <br /> ADDRESS L419�H�v <br /> SIGNATURE DATE Z <br /> H230038 (revised 30/12) <br /> 2 <br />