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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />U <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />ENVIROW-ENTAL HEALTH C@PARTMENT <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 FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />EPA Site # <br />Facility Name u 6Z <br />S <br />Address 7 G l C t{ <br />Cross Street <br />Owner/Operator l 4 4P <br />Contractor Name V­<,Lv ` e_ <br />Contractor Address �t <br />Insure% k <br />ICC Technician's Name <br />ICC Installer's Name <br />Tank system work area <br />p e 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Approved <br />Plan Reviewers Name <br />Project Contact & Telephone # <br />1/I"Z A- I Phone # <br />H r ( 1 H A n <br />Tank Size <br />Phone # c [l� <br />Phone # -? _1 L 3 <br />CA Lic #�—�js- ` Class 4 <br />Work Comp # <br />Expiration Date <br />Expiration Date <br />Chemicals Stored CurrentlyI Date UST <br />Installed <br />/25\Approved with conditions <br />1_A achment With Conditions) <br />7 <br />Disapproved <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 />Title 1/,' 1� i <br />BILLING INFORMATION.- <br />Indicate <br />NFORMATION: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. <br />NAME i .[ A �� TITLE 'CfC Z/li'L > �G���_ <br />( ?S PHONE # <br />ADDRESS 7c( L^ — LJ �G 4 `1. L L P -17L_ L -/T <br />SIGNATURE_�Z.c<<a 511C1_ DATE l, <br />EH230038 (revised 10/30/12) <br />2 <br />