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ENVIRONMENTAL <br /> EALTH 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 D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> A EPA Site# 7-0 , <br /> Project Contact&Telephone# N;C L <br /> C Facility Name - <br /> i Phone# ��^� � <br /> L Address 2,Dct_gZ l L? <br /> I W <br /> T Cross Street <br /> Y Owner/Operator <br /> C Contractor Name ' Phone# <br /> TN -' -1(o b <br /> Contractor Address •� Phone# <br /> R '4.._ f '7 <br /> A Insurer CA l is# 7 760 Class <br /> C I C <br /> T ICC Technician's NameWork Comp# 7 <br /> o � <br /> R )CC Installer's Name '— _ Expiration Date <br /> l�J Expiration Date <br /> Tank system work area 2 20 k� <br /> (i.o.87 piping sump, <br /> 91 leaf dolector,UDC 112 eta) Tank Size j Chemicals Stored Currently <br /> Date UST <br /> T %e Installed <br /> A <br /> N <br /> K <br /> I <br /> i <br /> i <br /> P ❑ I _ <br /> L Approved ❑ Approved with conditions <br /> A ALTH <br /> ❑ <br /> (See Attachmel�t With Conditions) Disapproved'ARTMENT <br /> N Plan Reviewers Name <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SA <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 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature �� <br /> Title Date l <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 i na q TITLE �,{Uj C� S <br /> CPHONE# �- -`�t�- ,��j� <br /> ADDRiSCSS 'c� 2 i 7 4 <br /> SIGNATURE 7 <br /> EH230038(revised 07-17-2414) � DATE t r <br /> ZV <br /> 2 <br />