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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTYIII k"'1111,1i <br /> "EIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 0 C T 2 0 2014 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK VIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name 71l S H` Phone# <br /> I Address <br /> L 7 G'G' vy,L'/LL a <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> o Contractor Name Ev �� Cc� (� y Phone# 7 e <br /> N Contractor Address P 6 CA Lic Class <br /> T �, S„1 5 3 s' <br /> AInsurer — Work Comp# <br /> T ICC Technician's Name / ��Z3 t Expiration Date pf �7— ( ,5— <br /> RICC Installer's Name - � �� Expiration Date �� s <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 �' /� ze & 33 <br /> r� <br /> A <br /> N <br /> K <br /> P ❑ Approved approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) � <br /> N Plan Reviewers Nam / 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." 11 a ) <br /> Applicant's Signature Title Date L b ( 1Y <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 bellow. <br /> NAME L (/S'X/ AJ Y ?-9 M 4- k TITLE N%� �j �� PHONE# V <br /> ADDRESS 7 / &,C: A-10A-( a L d C <br /> SIGNATURE 4 A 40ADATE <br /> EH230038(revise 0/30/12) <br /> 2 <br />