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03/11/2016 18:58 9163712540 BZ MAINT PAGE 02/03 <br /> 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 FRUM THEAPPROVAL DATE, INDICATE PERMIT TYP`er BELOW <br /> 17 TANK RETROFIT Ci PIPING REPAIRIKETROFIT ❑UL)(; RE=PAIR]RETROFIT C COLI] STARTILVR UPGRADE <br /> F EPA Site# Project Contact&Telep}cane <br /> A <br /> G Facility Nance Phgn9# L <br /> L Address ell jj,<J y <br /> TCross Street Y <br /> Y Owner10perator (�y� Y-Y"\ phone# <br /> G Contractor Nance Phone# <br /> 0 <br /> N <br /> T Contractor Address CA Lic# Class <br /> R Insurer <br /> A Work Comp# <br /> o ICC Thniolan' <br /> T ecs Name µ Expiration Elate <br /> R ICC Installer's Name Expiration Date <br /> R <br /> Tank system work areaDate UST <br /> (1,@,07 G!pinA sump,9i leak detaoloi,U6C 112,etat Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> M <br /> P ❑ Approved ❑ Approved with condition; ❑ Disapproved <br /> L <br /> A (See At(achirlent V%lith Corditions) <br /> N Plan Reviewers Name <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACJfN COUNTY ORDINANCES,STATE LAWS,AND 1`0I FS AND REGULATION3 OF SAN <br /> JOAQUIN COUNTY, ENVIRONNTNTAL HEALTH nEPARTMENT. OWNER OR LICEN ED AGENT'S SIGNATVRE CERTIFIEu THE FOLLOWING: "I CENTIFY THAT IN <br /> THE PERFORMANCE OF TI1E WORK FOR WHICH THIS PGRMIT 1S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN UUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE F(DLLpWING: 'I CERTIFY <br /> THAT IN THE PERFORNIANOE,OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT 7'0 WORKER'S COMPENSATtpN LAWS <br /> OF CALIFORNIA.' t <br /> •r I.applicans'6 3:gnstur8 �' a �?t C��� Title �"1(A���i-t-T l <br /> BILLING INFC)RMATION: <br /> Indicate the responsible party to be biiiod 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.9, property owner, the party must acknowledge this <br /> responsibil r the billi signature and date below. <br /> NAME [�(/ TITt-E MPle T_ PHONE <br /> ApoRESS � <br /> SIGNATURE DATE <br /> EH23DD38 Creviced 10130/12) <br /> 2 <br />