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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 <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 /> C Facility Name ci Ct h C v y D+� Phone#,?0 —3 3 c/ —0 7 j� <br /> � Address ecl ,;z <br /> I Cross Streetw Z <br /> T <br /> Y Owner/Operator Phone# 5_3 CO .3 )'K — 06 <br /> C Contractor Name <br /> o �vo(eVyK 5tvU+�r j.� o Phone# <br /> N Contractor Address -2;2 <br /> T ,0 CA Lie# Class G-R Insurer T D V� <br /> A !�/6lcv�' �!`y CUu rf�JJ <br /> �kG�-,ctcK,'� CO , Work Comp# <br /> TICC Technician's Name � ,src h Expiration Date <br /> RICC 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.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions _ Disapproved <br /> L ��eeAftachment 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 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 OE THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." i <br /> Applicant's Signature !�� Title `� r C_ f Date 2 ` 2 1 <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. pay, r� g <br /> NAMETITLE //►TH✓�T1�� PHONE# 5-Yb 3 r3501, ` <br /> ADDRESS01 2 I C <br /> 1 � <br /> SIGNATUR� �— DATE _ l <br /> EH230038(revised 10/30/12) <br /> 2 <br />