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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# `y/ 6 <br /> A ( ✓wn <br /> O Facility Name (Yo Phone# r 6(D-�- <br /> I Address 3 yZ5 j (-A C,n aI vd. <br /> T Cross Street L j^ <br /> Y Owner/Operator C- S C©t t L S-i G r Phone# '.6--TO-6.2/- Q-2 v <br /> C Contractor Name Phone# r <br /> N Contractor Address CA Lic# Class <br /> T 7517 S;�r/'� .�+^t S � <br /> R Insurer <br /> A r Work Comp#uT1"tJ(i7 ` S/ <br /> cecnician's Name <br /> T ICC Th3oc_ Set`nG Expiration Date fV)Cr S O/ <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 F7 :&!j2kon 1 vnN by 7 l�(r�o�✓� <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name _2L-4 � cy 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF WORK FOR W ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Sign re Titl .� f Date / <br /> BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this respo slbility for the billing by signature and date below. <br /> NAME and�Q rot:,.�in TITLE �S e r u,"c P 11 C. SONE# �,.0 <br /> COn•tr�cyp/' � _ <br /> ADDRESS <br /> SIGNATUr DATE =t`✓l 6-, -Z0� <br /> EH230038(revised 07/22/10) <br /> 2 <br />