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0 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 />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # J <br />Project Contact & Telephone # <br />O <br />Facility Name G�Q v <br />Phone # _ 93 f _ 6�/ S -V <br />L <br />Address I 2L 7TH' CA z <br />TCross <br />Street' <br />Y <br />Owner/Operator f �I�— <br />Phone # 7 o _ n <br />C <br />Contractor Name A7 <br />Phone # <br />N <br />T <br />Contractor Address y -(n /�' r� CA Lic # n ,, S Class . <br />RInsurer <br />A <br />Work Comp # <br />TICC <br />Technician's Name <br />Expiration Date ,1 le f 3 <br />QICC <br />R <br />Installer's Name /tom,., C . <br />L� / <br />Expiration Date �f / <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stared Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />L, Approved Approved with conditions L,, Disapproved <br />L <br />_(See Attachment With Conditions) <br />N� <br />Plan Reviewers Nam L 1 _ Date /2-0 3 -APPLICANT <br />MUST PERFORM )(LL 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 WOR F R 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY <br />THAT IN THE PERFORMANCE TH ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S OMPENSATION LAWS <br />OF CALIFORNIA." <br />j <br />App@cant's Signature Title ( pate <br />tll � V <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. r <br />NAME 1TITLE C ' A. (w. PHONE # <br />ADDRESS <br />SIGNATU <br />EH230038 (revised 08/1111) <br />K <br />