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ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave.;, Stockton, California 95205 <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 /> D TANK RETROFIT 0 PIPING REPAIR]RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> A {�EPA Site# c—'P' . <br /> Project Contact&Telephone# jJ C <br /> C Facility Name ;I IIIIII. <br /> Phone <br /> L Address <br /> I <br /> T Cross Street <br /> Y Owner/Operator <br /> C Contractor Name Phone# <br /> TT N Contractor Address Phone# <br /> .3 _ t � <br /> R I <br /> A nsurer i CA Lic# 77t>� Class <br /> c <br /> T ICC Technician's Name Work Comp# a 7 <br /> !CC Installer's Name Expiration Date <br /> 0 Expiration Date 2 20 Lq <br /> Tank system work area <br /> (I.e.E7 piping sump.91 leak aoleaor.UDC 1/2 atc) Tank Size Chemicals Stored Currently Data UST <br /> T %e Installed <br /> A <br /> N <br /> K <br /> i <br /> I <br /> I <br /> i <br /> Pn I �+s <br /> L ❑ Approved "�Approved with conditions Disapproved v <br /> A �`SWith,ee Attachment h Conditions). <br /> N Plan Reviewers Name e II, <br /> Date 47 7 )RSA I <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 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,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature <br /> Title L� c <br /> Date l <br /> Indicate the responsible party to be bitted for additionaBIIEHIC7 <br /> D staff timob expended d.b <br /> the party designated below is different than the permit applicant,I e. ey0nd permit payment coverage per tank. If <br /> responsibility for the billing by signature and date below. g. property owner, the party must acknowledge this <br /> NAME ry i C na�a c Qroc,rr c I- i� <br /> TITLE Zvi CSP S PHONE# ' <br /> ADDRESSAJ EV* <br /> SIGNATURE <br /> EH230038(revised 07-17-2014) <br /> 2 j <br />