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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 *IPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT D COLD STARTIEVR.UPG ADE <br /> F EPA Site# Project Contact&Telephone K F 1' ni an -7,1z4o 32 It 2— <br /> A Facility Name i I T Y <br /> � <br /> Address YW3 <br /> T Cross Street <br /> inilBtylal Rood <br /> Y Owner/Operator S Phone# q I W-CM <br /> o Contractor Name —" t F-nVir0nMfn-fCl 15tKYU5, 1 0C. Phone# -1 1-4 - 5W-7 (1j4 10 <br /> N Contractor Address 2 111 S , I Ve I Afl 0 j1plfilCA Lic# 0q Class A.5,C 10 H <br /> T <br /> A Insurer TyaVeWStj r O of AnnaWork Comp# g_ Q - L- 12 <br /> T ICC Technician's Name S 15 Expiration Date <br /> RICC Installer's Name S t' Expiration Date g ) <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T Pipinq SUMP u, ODD 310D Tony, <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A ment With Conditions) <br /> A /O <br /> N Plan Reviewers Name 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 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." L ((yy //II <br /> Applicant's Signature Title P I U Date I V / ZA 120 12 <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. EY In pan p fOYd - 714 <br /> NAMETOI t EL—n V I f A nt I I tO I TITLE t PHONE# �J(D Q 200 <br /> ADDRESS 2IJI 3. buoont DYiV2 AnLlr)-bM CIA PZHU <br /> SIGNATURE DATE 1 01 41 O 1 <br /> EH230038(revised 08/1/1 <br /> 2 <br />