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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 TWE BELOW: <br />O TANK RETROFIT O PIPING REPAIRIRETROFIT 'VUDC REPAIRIRETROFIT O COLD START/EVR UPGRADE <br />F <br />EPA Site# <br />Project Contact&Telephone# <br />� <br />Facility Name 54,E',o_ �^ a�10'1 <br />Phone# app_ Lk'l�-�laoo <br />I <br />L <br />Address� <br />���5 T.A.NCA <br />TCross <br />Street <br />Y <br />Owner/Operator Sq-�.'�w�. Nor�-`n�... C' �`(Z k-zar,: a <br />Phone# <br />o <br />Contractor Name �j� �� �r <br />Phone # "'� p -'t _ Sq t _ 'j -t S \ <br />T <br />Contractor Address <br />CALic# g4la0�k1 Class t,)\'Z, <br />A <br />Insurer C oM c <br />Work Comp # ooSooSBq tooa. <br />c <br />T <br />ICC Technician's Name c tn:nV <br />Ex (ration Date <br />P q-lo-ty <br />RICC <br />Installers Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leek detaaor, UDC 12, N,) <br />Installed <br />v �Sz, <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 />HE 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 PERFORMANCEAFTAE WORK FOR WH�THIS IT ISISSUED, I SHALL EMPLOY PERSONS SUBJECTTO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIAApplicant's <br />Signature 4en >r <br />V <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 Z> r � r r �-a TITLE Pe- } PHONE # SSO <br />EH230038 (revised 09/1111) <br />Fd <br />lA " 9 <br />