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ENVIRONMENTAL HEALTH 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 />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT FUDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact &Telephone <br />� <br />Facility Name yV oc" Phone#Q7� ( '�S <br />IAddress <br />L <br />r.J Gv �L✓O <br />TCross <br />Street ? 7 <br />Y <br />Owner/Operator, <br />Phone # 9 <br />oContractor <br />Name ,/' <br />Phone # <br />N <br />Contractor Address 2-91 +;[.G�yl <br />R <br />A <br />insurer <br />Work Comp # Gj 0730 7 <br />C <br />ICC Technician's Name ��/'� �mNG <br />Expiration Date -7 — ® ` 2.,Of7 <br />QICC <br />R <br />Installer's Name I/� �T®iv <br />Expiration Date /—/5-- a0/ <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, eta) <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Date l <) ' �7►1 1(fj <br />Plan Reviewers Name <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 PERFORWNCEFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />g Title Date <br />Apptcan s igna re <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 />� 1G4 <br />/� / <br />/4 <br />NAME <br />- "466 LE TITC.���% / i�L- PHONE# 7-oPW5_- s�� <br />,;�X ap <br />TE t�ir <br />EH230038 (revised 12-11-15) 2 <br />