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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 TYPFF//BELOW: <br /> D TANK RETRO 0 PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D CO b START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# t 11-4 a„1 `t$'3 ?753 <br /> MI `7 <br /> C Facility Name VH I c'�� FI"Y 5 S Cc Icdc- 8z r3 <br /> IAddress 3S <br /> I Cross Street ftil' <br /> Y Owner/Operator V q u t c ��rolY Phone# '711.? 875 3 <br /> CContractor Name hawk Tc Phone# <br /> N Contractor Address &o'7 C r Vuc..u�l�t %CALic# �p 'jos- Class /} <br /> T <br /> R <br /> Insurer Work Comp# tZ.wtzsflogG <br /> w e <br /> C ICC Technician's Name lsecr' Expiration Date <br /> T <br /> GICC Installer's Name it Expiration Dale �/Y <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.81 piping sump.91 leak dereaor,UDC VP,arc) Installed <br /> T N „ IZoo 7 VH F3-7 7N <br /> A <br /> N <br /> K <br /> P ❑ Approved / ❑ Approve ilh conditions ❑ Disapproved <br /> L ,(See Attachment h Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA E WITH SAN JOAQUIN COUNTY ORDI NCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPA MENT.OWNER OR LICENSED AGENTS GNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH TH PERMIT IS ISSUED, SHALL NOT EMPLOY NY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFOR A" CONTRACTOR'S HIRING OR SUBCONTRA ING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY RSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Date <br /> j BILLING INFORMATION: <br /> Indicate the responsible party to be, illed for additional EHD staff time expended beyond ermit payment coverage per <br /> tank. If the party designated below different than the permit applicant, e.g. property owner, a party must acknowledge <br /> this responsibility for the billing by nature and date below. <br /> NAME TITLE PHO # <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 07122/10) <br /> 2 <br />