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• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVEL; <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 APR 2 9 2015 <br />APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br />RETROFIT OR PIPING REPAIR PERMIT t.IC41Tu r)CD6QTA4I=KIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 0 PIPING REPAIRIRETROFIT KUDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # /NAC)--Wfni%' _ � <br />A <br />G <br />Facility Name <br />% <br />Phone # _!2 404_ <br />1 <br />L <br />Address <br />VIVO <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />��� <br />Phone # <br />oContractor <br />Name �'� <br />gum A)e`' Phone # g - <br />N <br />Contractor Address U <br />e gtf CA Lic # Class <br />A <br />Insurer <br />/ r�j�'v. <br />Work Comp # 9p 7E' <br />TICC <br />Technician's Name �" <br />Expiration Date <br />D <br />R <br />ICC Installer's Name O'?A -Irk C e - R -o <br />Expiration Date .. 7 —,;?o/7 <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />4-1 "t Fl It !L- t) e--- <br />A <br />N <br />L <br />Ae-A&- Com' <br />P <br />❑ Approved <br />Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name]�S <br />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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN <br />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 ZZ, <br />Title ���� ; Date t _ r <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. //►► //�/!r <br />NAME J1,6gle= TITLE .- PHONE # <br />SIGNA <br />EH230038 (revised 05-17-2014) <br />TE <br />