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• 0 <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 /> THI,WRMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIVT <br /> IPING REPAIR/RETROFIT O UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 4n-HA{Q.LES. YcM2Y— <br /> A ✓ <br /> C Facility Name V Q� Phone# <br /> � Address 1556. 1k'TV1 GtY �racqCA Q <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> D Contractor Name fJ�iO Phone# g'31.L '{�^. N <br /> 0 <br /> NContractor Address CA Lic# g61 Class Z <br /> T <br /> RInsurer M Work Comp# Wit,0b11 3001 <br /> A <br /> TICC Technician's Name Expiration Date <br /> a ICC Installer's Name ).- Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> Ii.e.87 piping sump,91 leek detector,UDC la,etc.) Installed <br /> T TL /I,I P 06 1 1O t1lu L A4�PVA/6 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A /�tt�// <br /> N Plan Reviewers Name Date 066 <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 WORK F07"ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /J/ ,,�� �� /� <br /> Applicant's S' ure / Title dd>w 4��ff..-,A�T Date �/r%S <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_T_TZ T CIONS I TTJC?/ON TITLE !>Yu/14!5!P �/ <br /> I 6 PHONE I�B3 -7- /72 <br /> r+� <br /> ADDRESS t2SGa ��� �- AVP!- 0-,2-`C0- e� <br /> SIGNATUDATE <br /> EH230038(revised 08/1/11) <br /> 2 <br />