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ENVIRONMENTAL HEALTH DEPART <br />NENIT- <br />SAN JOAQUIN COUNTY UUVED <br />1868 E. Hazelton Ave., Stockton, California 95205 NOV 0 9 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANKENV1RwnMENTAL <br />HEATH r1r:PQQTA=AIT <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT `I�PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # <br />Facility Name ,1C Phone _ (_ a <br />Q <br />I <br />Address `- 's -�7� <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />0 <br />Contractor NameVWCO <br />Phone # r♦` 1 <br />N <br />T <br />Contractor Addres <br />CA Lic # � Class _ <br />AInsurer <br />e� �(' c� <br />Work Comp <br />TICC <br />Technician's Name — cj <br />Expiration Date <br />R <br />ICC Installer's Name it tiD <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 Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />N <br />(S attachment With Conditions) <br />Plan Reviewers Name MLC,t 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 />Applicans Signature TitlefYMOP \ANh `f\/C4A( Date <br />A \ <br />- - - A <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 TITLE PHONE # "\� <br />AD <br />SIGNATUR <br />EH230038 (revised 07-17-2014) <br />2 <br />CA <br />