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11/24/2014 17:01 2058251004 THEUPSSTORE PAGE 04;'06 <br /> ENVIRONIV_ _NTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTYI ® <br /> 1868 E. Hazelton Ave,, Stockton, California 95205 e� CC <br /> Telephones (209) 468-3420 Fax: (209) 468-3433 <br /> NOV 242014 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETRO,I'T OR PIPING REPAIR PERMIT"ENVIRONMENTAALApHEALTH <br /> THIS PERMIT EXPIRES Sao DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ��P��TIVtCl�<i r <br /> 0 TANK RETROFIT 0 PIPING REPAII41RETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone# <br /> I <br /> C Facility Name r' Phone# n <br /> Addressj 7-0c, 3 —9-9-4 <br /> TCross Street , <br /> Y Owner/Operator `-�" Phone# ._(t <br /> o Contractor Name L Phone# fd—Z <br /> N Contractor Address r CA Lie# <br /> T 7" vW Class A <br /> A insurer I Work Comp# <br /> TICG Technician's Name r r5`' " C Expiration Date <br /> aICC Installer' N <br /> R s Name to i.J 2S Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (L e.87 piping sump,91 iaek a4Kector,UOC 1/2,etc—) � y Installed <br /> T n A— 10,0DO <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions [ Disapproved <br /> L (See A chment With Conditions) <br /> A <br /> N Plan Reviewers Name. \ + ' Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE�MTH 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 FOLLOW NG: "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 OFITE WORK.FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> kppllcsnfis Signature ��-- Title i Dace <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 S IAC�I V Jle fid° U� TITLE MO1/IG1J PHONE# L��0 <br /> ADDRESS Sr M <br /> SIGNATURE Z1,A DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />