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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 <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name G•6 e ri/v j ;� <br />Phone # <br />I <br />L <br />Address 4 02 C - �,F L, (j1 o Cj —.33 o? ? <br />TCross <br />Street w, f <br />Y <br />Owner/Operator <br />Phone# 5J-0-31? l30 b <br />C <br />O <br />Contractor Name r�o ��� y,^r ,-� �^ <br />J, A <br />Phone # <br />T <br />Contractor Address !7 h d �%, u f a� ( <br />CA Lic # 9 % 7 ?a 7 Class <br />RInsurer <br />A <br />E C�l� Cp vx C J•�% —� <br />Work Comp # <br />TICC <br />Technician's Name <br />Expiration Date , ' p`' O <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />�,F1C <br />l0 OGS J <br />T <br />�/r�Ar <br />A <br />g 7 IP <br />/(g"c c) VIN <br />oc- <br />K <br />I iJLI`Y <br />00 <br />Ly ©Gj <br />;c.sc I dr✓t Sz e✓jc,21 <br />00 U <br />j, S -e- <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(Se Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name. Y Date_A� <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 E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />'t <br />Applicant's Signature Title 'f 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. qn 5 r) JQ <br />NAME-51f- VV TITLE PHONE#✓J�y ��`y '(�D`' <br />ADDRESS ( / ,2, ( C��f �2� 1"7W_- <br />SIGNATLIRE�4 —DATE <br />EH230038 (revised 10/30/12) <br />2 <br />