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.. .. -�, lA` yt A 1 ". •y y ..•A �',"Myrµ... NY j yf y IhxY wU <br /> Y� <br /> li y yy G,� h h F y r l 1 44 1 t 11y ttrj y ' <br /> r r r <br /> i <br /> I ' <br /> 1 <br /> A ENVIRONMENTAL HEALTH DEPARTMENT <br /> I Y .SAN JOAQUIN COUNTY <br /> E 600 East Main Street, Stockton, California 95202 <br /> ' y 1 Telephone: (209)468-3420 rax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROIUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> f D TANK RETROFIT D PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility N \ Phone#06q) —ail <br /> L Address F: l�C����(C 1��ti x tl (.,A j 2 12) <br /> 1 Cross Street <br /> Y Owner/Operator <br /> [ Phone# <br /> G Contractor Name <br /> o Phone# <br /> N Contractor Address CA Lic# <br /> Class <br /> A Insurer <br /> \ a Work Comp# <br /> c ICC Technician's Name <br /> T Expiration Date <br /> oICC Installer's Name <br /> R _ Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> em <br /> (I.e.87 piping sump,91 leak detector,UDC 112,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved `0-,Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> r <br /> N Plan Reviewers Na .114 <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,t SHALL EMPLOY PERSONS S RE CERTIFIES <br /> WORKER'S COMPENSATIONN : " CERTIFY <br /> OF CALIFORNIA.' <br /> Applicant's Signature ,�� TltleAe�� ' �I� 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. <br /> �ry-��r �iimC�l+l� L <br /> NAME��I�LI�(°�(�IRK�CZ 1 Q \ Cj TITLE ElP�f� ��F) .PHONE#__25:1 L _ <br /> ADDRESS <br /> SIGNATURE_ DATE___ <br /> (� 3 <br /> EH230038(revised 08/1/11) <br />