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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 NOV 12 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TAIMVIRQNMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HEALTHncceorlucnrr <br /> THIS PE MIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT IPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name r -e Phone# -)Le <br /> � <br /> Address �B 7 <br /> Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name Is-en Phone# <br /> 0 <br /> N Contractor Address /USS CA Lic# ,�59 Class <br /> R Insurer Work Comp# <br /> A <br /> T ICC Technician's Name / ti r2 s S Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.a]pipiig Bump,gt kak detector,UDC 12,etc) Installed <br /> T k2 nit tl 1 CC' <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S ttachment With Conditions) <br /> A �I (�/� <br /> N Plan Reviewers Name n�i of 1 1 1m-;40 Date <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 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 A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> Applicants Signature Title `! Date [ 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 /> NAMEX /a tf" 3 YU TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE r5l0k DATE <br /> EH230038(revised 10/30/12) <br /> 2 <br />