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NMNTAL HEALTH DEr ARTMEN;T.F� ,, '__t <br /> E NVI RO � � �_����� �x, � n <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAIC 3 0 2016 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIttONMEN TAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERIVII <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT -]$COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A y t I G.. 1 r,� Phone# ;� G% <br /> C Facility Name <br /> 1 Address�G �C` i •� L <br /> L <br /> 1 Cross Street <br /> T Phone# <br /> Y Owner/Operator 77,v, <br /> C ) �, Phone# <br /> o Contractor Name v <br /> T Contractor Address ?,a f��, S y .. ��� <br /> CA Lic# S- ��S Class <br /> R Insurer . " Work Comp# <br /> A v <br /> C ICC Technician's Name Expiration Date C��t 7 —i <br /> O ICC Installer's Name tG Expiration Date <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i_e.87 piping sump,91 leak detector,UDC 112,etc.) <br /> n <br /> N <br /> K <br /> P <br /> ❑ Approved 1�Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers NameC �� 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 WORKER'S COMPENSATIOHE WORK FOR N LAWS OF CA ORN AICH S PCONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A IFIESTHEHE FOLAS TO BLOWINGECOME SUIBCERT 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 Signatur ,L. �h ({✓L� Title -✓`4' l!" Date f <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 patty must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> �-- <br /> ' NAME TITLE t�Ct•<"�` i w.G�.-�••c r" _PHONE# CI <br /> XADDRESS �� =ri_G Ski: �t �c.• Cts t15 <br /> SIGNATURE DATE <br /> EH230038(revised 10130/12) <br /> 2 <br />