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��,. I rte' ��,rr' i r , r • •�r r•�,f•M• 1ra {r^��•,� . • r '1 ' q <br /> 7 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> I 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 O UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> EPA Site# Project Contact&Telephone#. <br /> C Facility Nam <br /> Address �� Phone# <br /> I Cross Street <br /> Y Owner/Operator <br /> Ohone# al LtJt ' <br /> ContContraCtor Name <br /> oPhone# <br /> T Contractor Address 2N 14/Dj <br /> R - j CA Lic# Class <br /> A Insurer Work Comp# <br /> T ICC Technician's Name s <br /> .0 Expiration Date <br /> R ICC Installers Name <br /> Expiration Date <br /> Tank system work area Tank Size Date UST <br /> O.e.87PIPing-UMA 91 leakadedor,UDC irz,e1.l Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions <br /> ❑ Disapproved <br /> A (See Aft hment With Conditions) <br /> N Plan Reviewers Name Date YY// ((6 ( /3 I3 <br /> APPLICANT.MUST PERFORM ALL WORK IN CCORDAN E WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN.COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS 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 AMANyER.9S.T0 BECOME SUBJECT TO <br /> WORKER'S-COMPENSATION-LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SURE GE TI 18S T E FOLLOWING: <br /> NSATI C LAWS.. <br /> HAT LI ORNIA. - - — <br /> _ OF CALIF - <br /> APPlicanrs Signature Dat <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 /> {iHllhk4tit .1 d <br /> b <br /> NAME Ei I1E.al cn(1TR,pcn a5 rYnc, TITLE_r1P11( Y>1 +��cJ PHONE#� 4(OI d <br /> .. . ADDRESS- 2 �S.,1�.1('Stt.`l4'(61 <br /> SIGNATURE_.�hon (k�614f) DATE C_O'V <br /> EH230038(mvised O8/1/11) <br />