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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 TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Qb V p-C_e SCJ <br /> Facility Name Phone# <br /> IAddress <br /> ITCrossStreet <br /> Y Owner/Operator Phone# <br /> oContractor Name L C, Se -V G P S Phone# <br /> N Contractor Address 3gg-� �( , U�eti}���� N-� CALic# '- I9 - KA 7— <br /> T a-lp-7 Class <br /> R Work <br /> A Insurer Comp <br /> C p3 01 5R�ao:L <br /> T ICC Technician's Name ('p�R� �A1rri S rj�S-F� (pQ Ct t' Expiration Date,jl)lJ j0, '�\� <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 1/2,etc.) Installed <br /> T (J CeS rt3:n� 5p. <br /> A <br /> N <br /> K <br /> P Approved .Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A , n , IM <br /> N Plan Reviewers Name l I NIS �vv�- Date -,2, <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 AGENTS 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 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 Signature Title Date 31 <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 b-illiin�g bby(signature Lndd diale belpw. <br /> NAME �� � V^�/� �� TITLE Gr.1.35'_jaJCkLCA-) PHONE#c5s:q )4cca-cl3G <br /> ADDRESS L.C V-x(_-e AZ LV_ ka ),jG' M Cc3 Z a-::2- <br /> SIGNATURE DATE <br /> EH230038(revised 07/22/10) <br /> 2 <br />