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�r yµYti J k�•..i t r! 1 1 I / I •1 / // -`1 t.�.s�+.6iN+ i w •:s R 11 1 ♦ A t r. I) /1 I 'R t <br /> �!t1�1 r• ,�;tZ 1 1 1'w Y 1 I A 1 R M+ R til�i`' Y HR Ri�� 1 1 xJ 1 Iw 1 t R R 1 R 1� 1'w* � <br /> E ' w a r w t 11 A •y i 1 w 1 R/ 1- <br /> i F1 1 <br /> < 1 • <br /> I <br /> / 1R f 1 wr <br /> I ENVIRONMENTAL HEALTH DEPARTMENT ` <br /> SAN JOAQUIN COUNTY <br /> 1 <br /> 600 East Main Street, Stockton, California 95202 <br /> { 1 Telephone: (209)468-3420 rax: (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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# _ <br /> 1 . _._ .. _ . . _- . <br /> c Facility Name Phone <br /> Address �— <br /> L � r('� r� <br /> TCross Street 11-'1 G <br /> Y Owner/Operator Phone r <br /> cContractor Name - I 4o <br /> o Phone# <br /> N Contractor Address <br /> r CA Lic# ���� <br /> Class �� <br /> R Insurer <br /> A 8 <br /> c Work Comp# r <br /> ICC Technicians Name "V <br /> r ' Expiration Date <br /> QICC Installer's Name <br /> R _ Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 Teak detector,uoc 112,eta.) Installed <br /> T <br /> A <br /> N <br /> K <br /> 01 <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name Qp/7 q Mol-)&1-0 - <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONSO F 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-COMPENSATIO LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM OF ThIE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS,SUBJECT TO WORKER'.S_C.OMPENSATION LAWS,, <br /> OF CALIFORNIA - -_ <br /> ,Applicant'sSignature_ Title - Date \ <br /> 1 <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 halnw <br /> NAME_ PHONE 4!, <br /> �L C - 90 <br /> ADDRESS 1\ IC NO _IiLi 5TOICU611') CP- CO'ZI Z <br /> SIGNATURE DATE �Tl� <br /> EH230038(revised 8/1/11) <br />