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0 4) RECEIVED AUG1. 1017 <br /> ENVIRONMENTAL HEALTH DEPA . <br /> SAN JOAQUIN COUNTY ' t <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> 17 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ���'�' � <br /> APPLICATION FOR UNDERGROUND STORAGE TAI L x`,!",J z:. LTH <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 40-,43 3? <br /> � Facility Name Phone# _, 14 73, 1 <br /> � Address `Z 6` C �(c( <br /> TCross Street <br /> Y Owner/Operator A P7 12 7AQ1Phone#2 a L( 3-- 3 <br /> C Contractor Name Phone# 3 <br /> N <br /> r Contractor Address c® k CA Lic# ' -'4 ClassV A C <br /> R Insurer Work Comp# j)l 3al <br /> A <br /> CV <br /> r ICC Technician's Name Expiration Date <br /> R ICC Installer's Name 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 <br /> A <br /> N <br /> K <br /> P ❑ Approved NApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name c 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 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 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 ° Title s Date S 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 below. 46k-Cul- <br /> NAME *t L Wilef4 TITLE CC14 o PHONE# b <br /> ADDRESS49t) 't LL V% SQ L, a <br /> SIGNATURE I DATE 1 <br /> EH230038(revised 7-26-2016) 2 <br />