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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE <br /> APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> R <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# .JC S-5C — <br /> � Facility Name �r'A.,) (:7L)LjI J P() UC WD :U&W d. Phone# <br /> Address /' / . !114 S LX) �2- <br /> Cross Street <br /> T W/ -sc,;J ' <br /> Y Owner/Operator S J Co, V t L W Phone 7�q r���� �0 7 <br /> CContractor Name �� j f Phone <br /> T Contractor Address �,j j jCA Lic# 77" r ��"Clas f) t i <br /> A insurerM��� � �✓/✓k)rilRt; � L L,,+A/4,f Work Comp# (.06U 00 S-i x'70 <br /> C <br /> T ICC Technician's Name p(-)14/t,;;Zr U 7`" Expiration Date <br /> R ICC Installer's Name ��g16„ � L) / Expiration Date <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 W L4C <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved 'h c9nditions ❑ Disapproved <br /> L (See Atta me I ond'' ns) <br /> N Plan Reviewers Name Date Pec 1 ?0 0 7 <br /> 4Z OL <br /> APPLICANT MUST PERFORM ALL WORK I ACJ <br /> DA E WITH SAN JOAQUIN CO6D /ENTS <br /> DINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL H LTHARTMEMT.OWNER OR LICENS SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALLT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM CE 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 Sionatw � Title I 1 w Date �✓ <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 /> responsibilitgy for the billing by sig`�nature and date below. 1+n,� n / <br /> NAME �J r� �T ht �sT Y TITLE i ?S✓ PHONE#'( ) r �� <br /> ADDRESS �U /� G� �'/� (�{�l !✓(1 �`-, <br /> SIGNATURE DATE <br /> EI-12300:318(revised 02/26W) <br /> 1 <br />