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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# DUp,AfF_ <br /> A Q_ <br /> G Facility Name v0 �{,E VoAIE r-d Phone# 2©q-5 Lfq--b-7oQ_ <br /> Address <br /> I Cross Street <br /> T <br /> Y Owner/Operator Sc4,e k4 Phone# 20Q-rj={q <br /> o Contractor Name L E.. Se r1 C4 S Phone# S'9o,-44 fi-.L-I,3 d <br /> T Contractor Address '348r6l tk. vp,'ke+-k-a A•cw- CA Lic# '(1q 2(p"I Class <br /> RInsurer <br /> A ASSLN-Djt« C,�7e-�(� Work Come# WGp3p"($$S.-jO-2... <br /> C ICC Technician's Name 1�.�C-, fit( <br /> T Q_V 6-p,�(���pp �p��,'j _u'�' Expiration Date <br /> RICC Installer' <br /> R s Name Q-UF3El•� l\►_)40 8018Q1 l-V l Expiration Date Jwe,2, Z,p kii <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.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved P'roved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> N Plan Reviewers Name "A'w I-100 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 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 L C�[�,, <br /> irixCES/Cel�. Date — 0_—a0t`Ii <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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 07/22/10) <br /> 2 <br />