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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 OCT 2 4 2014 <br />APPLICATION FOR UNDERGROUND STORAGE TAN K.-11RONMENTAL HEALTH <br />RETROFIT OR PIPING REPAIR PERMIT DEPAF--;'!`,k4 NT <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 />A <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />- <br />C <br />Facility Name � <br />Phone # <br />L <br />Address C A <br />LQUICRI <br />TCross <br />Street <br />Y <br />Owner/Operator <br />C <br />Phone <br />_ <br />Q <br />Contractor Name <br />Phone # <br />N <br />T <br />Contractor Address <br />CA Lic # Class <br />R <br />A <br />c <br />Insurer 'r <br />Work Camp t <br />l9- ii <br />TExpiration <br />ICC Technician's Name <br />Date <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 Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K- <br />P ❑ Approved pproved with conditions ❑ Disapproved <br />AA (Se Atta hm t With Conditions) <br />N Plan Reviewers Name <br />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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." ' <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. <br />NAME htft)RI� <br />I r.nc TITLEI_UUC �f -j(1 C PHONE # G.cT1 <br />ADDRESS_- ��C'ff) I s<)1(>l 1'PM U) V IVf C iVV7 LTi \ifs ,i In t vC n i\c . <br />SIGNATURE "r [M t 1MIJC) DATE jly&' 2Qg <br />EH230038 (revised 08/1/11) <br />2 <br />15 <br />