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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 OCT 16 2014 <br /> APPLICATION FOR UNDERGROUND STORAGE TAN6NVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT XPIPING REPAIR/RETROFIT n UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 2 "_ <br /> A <br /> C Facility NameI Phone# <br /> � <br /> Address315 115 t 00 11 CA <br /> TCross Street I r <br /> Y Owner/Operator I1 Pr 0 d U cts Phone# I 'b <br /> D Contractor Name T t V I $ Phone# 4 <br /> 0 10 <br /> N Contractor Address 21 I Iy-P , AndhOidCA Lic# S O C1 8 Class H A e <br /> T <br /> A Insurer roDmN cosuoitjWork Comp# _ <br /> TICC Technician's Name Expiration Date 1 12612-W3 <br /> R ICC Installer's Name t V k, nhorV Expiration Date 12 19 015 <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 WQStt ( rFlII SLEW00 51 OD T011 k <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L is e-A achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA 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." <br /> Applicant's Signature YU itle Date <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. Erin LO n gfo rd -1 14 _ <br /> NAME Tait FnVironm-ento I TITLE PCO If'Ct QI`l� PHONE# P)IOO - 8260 <br /> ADDRESS 21� I S , Dupont Dri Ye , Anaheim . cA <br /> SIGNATURE DATE-LU i 4 I L rl l4 <br /> EH230038(revisui <br /> ed 07-17-2(U) <br /> 2 <br />