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ENVIRONM NTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY _ <br /> 1868 E. Hazelton Ave., Stockton, California 95205 RECEIVED <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> MAY 15 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br /> H1=A.LTH DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# LP,,L"O0O 3q b, S Li Project Contact&Telephone# K 1ck-,JC,g pwe <br /> A <br /> c Facility Name LJ�kSQJ`1S ecct` Z Phone# Zo�—s'Z —Z7�� <br /> I Address \��j 7 s <br /> I c <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# � <br /> C Contractor Name Phone# SSq -LtgL(.- P??-d <br /> N Contractor Address vc1 CA Lic# 7-7 4co 7 Class A �C Orva <br /> T <br /> A Insurer Y� her ,�, L� Work Comp# .7 <br /> T ICC Technician's Name �� �Z Expiration Date (P S L`Z <br /> Q ICC <br /> R 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 pS L k lzvve- j�L es-e <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A '81,23112 , <br /> `` <br /> N Plan Reviewers Name Date 23 I l <br /> APPLICANT MUST PERFORM ALL WORK/IN ACCORDA CE 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 ISSUES,I SMALL EMPLOY PERSONS SUBJECT TO ORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." c <br /> Applicant's Signature Title �� \ 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 /> NAME_ TITLE) PHONE# <br /> ADDRESS �� "' ' V`A� vt-C „ "� <br /> SIGNATURE DATE <br /> EH230038(revised 7-26-2016) 2 <br />