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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 9.5202 <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 TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> G Facility Name &\.vVC( vakeXo t-tPhone# <br /> � Addresstk <br /> I Cross Street <br /> T <br /> Y Owner/Operator e0\44-14 PE*Tdt-r— M Phone# <br /> C Contractor Name L G C�-S Phone# 'j5q_L�l.44-k1d <br /> TContractor Address 3 N CA Lic# -119 Class <br /> R Insurer P\S5Urb1%jC_ cow__P Work Comp#��(C�j3�'�5$>��O'L <br /> A <br /> T ICC Technician's Name (9P." �kp-rr­iS _ Expiration Date 3 o <br /> R ICC Installer's Name _V i Expiration Date3 IQs-t( t <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> `' (i.e 87 pipings sump,91 leak detector,UDC 1/2,etc) Installed <br /> T �{ �-G <br /> A <br /> N <br /> K <br /> IP Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name l�� ' �� I� 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OFrEWORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." '- \ <br /> Applicant's Signaturelalj Title C aCUC cG.) SM Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. //����''``,�.��.."" � //,� <br /> NAME DVNW1��� TITLEUIJ�ItUC.A_C 5*"��c.�J PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 07/22/10) <br /> 2 <br />