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r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <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 /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C NMwVA- <br /> Facility Name - Phone# <br /> IAddress <br /> L <br /> TCross Street <br /> Y Owner/Operator \ Phone# %&11-65 <br /> oContractor Name Phone# <br /> 0Gm <br /> N <br /> T Contractor Address CA Lic# ClassAWAO 96 <br /> R <br /> Insurer ' a Work Comp# <br /> TICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> #.a.87 piping sump,91 leak detecim,UDC 1/2,elu) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S i Attachment With Conditions) <br /> A p <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACC NCE 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 SUBJECTTO <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 /> Applicant's Signature Title Dale <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 /> ' �iiml►k41t� <br /> NAME D t-[E.006VM&IaCTCP..S /Y"CJ TITLE�P�t��C11 '�"(t(P ) PHONE# ZCJA 4rUI-65M <br /> ADDRESS L�) 1 I i�1I1I1LL NJ�Y(� Tt�n t CX� 2 Q6 <br /> SIGNATURE _�h1.0.� DATE -dOr� <br /> - EH230038(revised 08/l/11) - - <br /> 2 <br />