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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 /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Emily Crain 916-371 -2380 <br /> Facility Name Cruisers 76 Phone # <br /> I <br /> L Address 1137 W Lathrop Rd , Manteca <br /> i Cross Street ------ <br /> cdyocyx <br /> Y Owner/Operator <br /> Phone # '�;Lj j 7 � <br /> 0 <br /> Contractor Name BZ Maintenance Phone # <br /> N Contractor Address PO Box 933 , W Sao , 95691 CA Lic # See attached Class <br /> A Insurer See attached Work comp # <br /> c ICC Technician's Name See attached Expiration Date <br /> T <br /> R ICC Installer's Name Expiration pate <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e. 87 piping sump, 91 IeaX detector, UDC 1 /2, eta) Installed <br /> T 87 tank - drop tube UNL <br /> A 91 tank - drop tube UNL <br /> K DSL tank - drop tube DSL <br /> P ❑ Approved Approved with conditions U Disapproved <br /> ( See L ( SAttachment With Conditions) <br /> A C% Datef 16 Cz � <br /> N Plan Reviewers Name CSL ' ` <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 PERFORM6NC OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." p <br /> ppllcant's Signature V V 7iUe 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 C> l C' G�r� l � TITLE V ( _ PHONE # <br /> XADDRESS <br /> r'; <br /> SIGNATURE 'L 4` --" DATE <br /> EH230038 (revised 12-11 - 15) 2 <br />