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\W01 lfto� <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 TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# XJ 71 <br /> � Facility Namen� fro h # rj y-Z6 Phone# 7/ 4"7/J J Jr6 <br /> � Address ,J 7S-/✓.SHG` j3/ <br /> Cross <br /> T CfOSS Street ^/ �Q <br /> Y Owner/Operator Phone# 7/Y C7/ ,jJAK <br /> o Contractor Name y y.44 ti G Phone# <br /> T Contractor Address,�D,y„y;N d�fi iT S �e C� CALic#„-j4"j-91,f' ClassA_1j•0-1?Nw <br /> A Insurer a4 „� .�w,fliry..ce o Work Comp# <br /> T ICC Technician's Name f0eN Zjgc4 �i �Z`f�l$ Expiration Date <br /> R ICC Installer's Name K-,4aZeef amara .S'//.f7J8 Expiration Date 9-26-LD/.3 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> I.e.B]piping sump,91 leak detector,UDC 1n,etc.) Installed <br /> T /97 4 W91 ,f <br /> A y' rl <br /> K G T7 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 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 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 Title � c.A%yog Date �149C— <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. Q / <br /> NAME L"Yll� / GVI�Y -fes G TITLES116/e '746—K-3 <br /> PHONE# <br /> ADDRESS J� I�'J7(q'i.g Ay/ seii is/S /'lti% Ci /.S—P-32 <br /> SIGNATURE JX 45 4� I&Z,60% DATE_ <br /> EH230038(revised 08/1/11) <br /> 2 <br />