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0 0 <br />copy <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />RECEIVED SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Callf.oMia 05205 <br />RECEIVED <br />DEC* 16 2013 tele'phone, (209) 468"3420 Fax: (209) 468-3433 <br />ENVIRONRENNAL APPLICATION FOR UNDERGROUND STORAGE TANK 16 2013 <br />EALTHT RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. WA" 08W. <br />oTANK RETROFIT 0 PIPING REPAIRIRETROFIT OUDC RE'PAIRIRETROFIT ISV-t OLD START]EVIR, UPGRADE <br />,F GRA Site # <br />Project. Contact & Telephone # <br />C Facility Name <br />. I Phone # <br />L Address <br />I I LL V 01.t 4 t <br />Cross Street <br />T <br />CI <br />Phone # <br />0 Contractor: 14 . am <br />N Vitc- -t) leo Phone 9 <br />T ContractorAd <br />R CA Lic # <br />A Insurer S. -fClass <br />C Work Como # <br />T ICC TechniciaWs Name C <br />0 Expiration Date <br />R— 1CC Installers Name ani 0 <br />- -------------------------------------- Expiration. Date <br />Tank <br />system <br />eMwork area. <br />rea Tank Size <br />Date UST8ipipI i,--kCIOI",U0C112,ett) Chemicals9toredCurrently <br />Installed <br />T <br />A <br />N <br />.K 7" <br />A <br />P, pproved Approved with conditions El Disapproav <br />L ed <br />A (See Attachment With Conditions) <br />(YlN Plan Reviewers Name gev� -0 —Date 1) <br />APPLICANT MUST PERFORM ALL WORK IN ACCO I RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER THE PERFORMANCE OF THE WORK FOk HEMI <br />THIS PER WN.ER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY AT IN <br />LAWS OF CALIFORNIA"CON N SUCH A MANNER AS To BECOME 81.164goT TO <br />WORKER'S COMPENSATIONMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON I W THAT <br />THAT IN THE FEAFORMANCI%0F THE TRACTOIk'b HIRING OR SUBCONTRACTING. SIGNATURE CERTIFIES THE FOLLOWING. "I, CERTIFY <br />OF CALIFORNIA.' WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />jA plican6:8ighatu,/ <br />3 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff timeexpendiad be <br />the part beyond permit.pay.ment Coverage per tank. it <br />,y designated. below is different than the permit applicant, e.g. property owner., the Party must acknowledge this <br />responsibility for the billing b <br />. y signature and date below. <br />NAME_l �L-A ITLE�-,PHONE# <br />EH230038 <br />2 <br />TE <br />