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y r r 7 rr ^ + r, ENV I AL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 f Telephone: (209) 468-3420 rax: (209) 468-3433 D APPUCATiON FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: CT TANK RETROFIT Q A1PITVG REPAIRIRETROFIT F EPA Site # O UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE C Facility Name Project Contact & Telephone 0 _ IAddress L f Phone C i _ T Crass Street p Y Owner/Operator C Contractor Name Phone # NT I ContractorAddress Phone# RInsurer , CA Lic # Class cICC T Technician's Name , Work Comp # R ICC Installer's Name Expiration Date Tank system work area— Expiration Date (I.c. 87PiPInp sump, 91 leak detector. UDC 1l2, etc.) Tank Size Chemicals 54 orad Currently ate UST T Installed A N K ' ly P ❑ Approved L Approved With conditions A (See Attachment With Conditions) ❑ Disapproved N Plan Reviewers Name _ - Date CANT MU9T PERFORM ALL WQRfC IN ACCORDANCC WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN E PERUIN COUNTY, ENVIRONMENTAL HEALTH bEPARTMENT OWNER QR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEp I SHALL NOT EMPLOY.ANY PERSON IN SUCH 11-IvIA�vNER AS N BECOME SUBJECT TO 4T IN rHE PEIZFO ATION LAWS OF CALIFORNIA." CONYRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING, "I CERTIFY CALIFORNIA MANCE OF Thli WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMFLQY PERSONS SUBJEC COMPEN _ TTO 'h1ORKE'S_COMPENSATfON LAWS - licanl's Signature - - TrII.PIP rwPzpr"-1iIttoN r-•1.,.1 n A - -- - IndicBILLING INFORMATION: ate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage er the party designated below is different than the permit applicant, e.g. property owner, the responsrbllity for the billingb sign and date below. g P tank. !f y ._g . _..__ Party must acknowledge this NAME�m�nt; ADDRESS �� PHONE I SIGNATUREt EH230038 (revised 0811111) KATE J P ❑ Approved L Approved With conditions A (See Attachment With Conditions) ❑ Disapproved N Plan Reviewers Name _ - Date CANT MU9T PERFORM ALL WQRfC IN ACCORDANCC WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN E PERUIN COUNTY, ENVIRONMENTAL HEALTH bEPARTMENT OWNER QR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEp I SHALL NOT EMPLOY.ANY PERSON IN SUCH 11-IvIA�vNER AS N BECOME SUBJECT TO 4T IN rHE PEIZFO ATION LAWS OF CALIFORNIA." CONYRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING, "I CERTIFY CALIFORNIA MANCE OF Thli WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMFLQY PERSONS SUBJEC COMPEN _ TTO 'h1ORKE'S_COMPENSATfON LAWS - licanl's Signature - - TrII.PIP rwPzpr"-1iIttoN r-•1.,.1 n A - -- - IndicBILLING INFORMATION: ate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage er the party designated below is different than the permit applicant, e.g. property owner, the responsrbllity for the billingb sign and date below. g P tank. !f y ._g . _..__ Party must acknowledge this NAME�m�nt; ADDRESS �� PHONE I SIGNATUREt EH230038 (revised 0811111) KATE J