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� 3osGD. t <br /> 5 + <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 G G G <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> JUN 19 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br /> THIS PERMIT EXPIftEe.780 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> HFIL!TNr1GDpCTAACNIT I <br /> O TANK RETROFIT D PIPING REPAIR/RETROFIT 13UDC REPAIPJRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Co5:a Pqo je )?9)-'14 2,I <br /> C FacflItyNameP'qWJ1O i' Yy)p Phone# R rr� <br /> I Address 14 a. ',T q <br /> L <br /> I Cross Street Qy� (,llQ <br /> TPhone# p <br /> Y OwnertOperater .P f� I'I) q� O <br /> D Contractor Name Shields, Har er& Co Phone# 510-653-9119 <br /> N Contractor Address 4591 Pacheco Blvd Martinez CA., CALlc# 803011 class C-61/D-40 <br /> R Insurer Santa Maria & Company work comp#57WEVK9673 <br /> A <br /> GT ICC Technician's Name Jeff Nelson # Expiration Data Oct 8, 2015 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> po.BTpiphq wmp.e1 bek deleelw.UDC IQ.M0.) Installed <br /> T Melt/' M t15,00 0 _ 0v rev <br /> A g <br /> N ('!! <br /> K <br /> I <br /> Q G <br /> P ❑ Approved ❑ Approve,with conditions ❑ Dial �---- ,/r' g( <br /> L (See Attachment Withbondilions) bvnrk— h0LO WVL�ri €( <br /> A �Y1 <br /> N Plan ReviewarsName __,_ Date d,o,�- SIe.b0-7Vj , <br /> — - 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN I <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN L <br /> ME 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 4U <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 /> I^ <br /> pilmntb SIgnatur � _Tes _ Dale `0 <br /> 1 IS <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff lime 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 r the billing by s gnature and date below. <br /> NAME_ io `FTP S TITLE �q{�"v�� PHONE <br /> 8 <br /> ADDRESS '' '" " -r -- <br /> SIGNATURE �� T DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />