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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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> D Facility Name 6""t at Phone# 264 <br /> Address 1 3:3 <br /> 1 Cross Street <br /> T /� �� � <br /> Y Owner/Operator , ( Z Phone#204 3 G 0-42 U <br /> C Contractor Name Phone# - 7—4 r0b <br /> T Contractor Address 1 U CA Lic# -7'7��Z Class � 'bZ j; D 3 j)q?) <br /> R <br /> A Insurer Work Comp#-73_0 d0 60 5 S9-- I <br /> TICC Technician's Nam �- Expiration Date (� 2 <br /> R , <br /> Q ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) 1 Installed <br /> T 1�,D00 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Aft ment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �Zy//2J <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 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 Date 1 Z' 12— <br /> BILLING <br /> ZBILLING 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 /> respon ibility for�the billinigby sig`natyre and date below. <br /> NAME)�� j�a Gt -f-��,On <br /> 0S NE# <br /> ADDRESS l l�lJ C) C) <br /> SIGNATURE1V IV DATE t Ojz /(Z <br /> EH230038(revised 08/1/11) <br /> 2 <br />