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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY (0 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 NOV 2 5 2014 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIIiUNMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> PEAMITjSEkVH ESTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ZO q-- .�Z <br /> � Facility Name 641 Phone# <br /> I Address <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name ` �' Phone# <br /> N Contractor Address'�p S� CA Lic# Class <br /> T <br /> R <br /> A Insurer Work Comp# C'3� <br /> T ICC Technician's Namef� �tyy1 5 �QQ 6 Expiration Date _ <br /> Q ICC Installer's Name �l Sr� �j Expiration Date 3 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N -- <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L S ftment With Conditions) <br /> A /,-Z �y <br /> N Plan Reviewers Name 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 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 '• Title A�� 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 TITLE PHONE#2 <br /> ADDRESS 1 `C <br /> SIGNATURE DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />