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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <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 XUDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility NamesRVE ON p-s V <br /> LI o Phone# . Z6 —4-4-0 Z) <br /> L Address Zo W o E- Ru E. HRUTECP, CAS 9 <br /> T Cross Street U E- <br /> y Owner/Operatorj N E I LA'W I Phone# Zo `r Z6 <br /> oContractor Name Phone# <br /> N Contractor Address P.O p p O{}K ' 9 CA Lic#�O'� 3 3 o Class <br /> A Insurer LS Work Comp# qO S — 20P0 <br /> T ICC Technician's Name RTH RI 6114 T Expiration Date (j'3 l 3 20 I <br /> R ICC Installer's Name It IKE Expiration Date O <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump.91 leek detector,UDC Ia.e1c) Installed <br /> T 2000 G1kG AS <br /> N GR As <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name j.lr.A _Date �3 <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 PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ('� p '{ <br /> Applicant's Signature Title i/�NF—rte Date o� �/I <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. C n r� q <br /> NAME _ (1 SI W4 E �AJ 1y l� l� GD I — 241 -44-0z) <br /> J TLF �1 n PHONE <br /> ADDRESS 0 It) �Er MONTECA , LA- <br /> SIGNATURE DATE 0312-612,1 <br /> EH230038(revised 10/30/12) <br /> 2 <br />