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j <br />• MENTAL ALT EPA T <br />T - <br />SAN JOAUIN COUNTY <br />600 East Main Street, Stockton, California 95202 " <br />Telephone: (209),468-3420 Fax: (209) 468-3433 <br />w APPLICATION FOR- UNDERGROUND-�ST®I agG .TANK <br />RETROFIT O PIPI G REPAIR PERiT "" <br />11 TANK RET APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />ROFIT ❑ PIPING REPAIR/RETROFIT 13U <br />THIS PERMIT EXPIRES 180 DAYS FROM THE DL REPAY R UPGRADE <br />REPAIR/RETROFIT ` ❑ COLD STA RT/EV <br />F EPA Site # Project Contact & Telephone # <br />A p <br />G Facility Name Phone <br />L Address4 5b <br />q 4 <br />TCross Street <br />Y <br />Owner/Operator Phone <br />FC <br />ContractorName <br />Phone# <br />Contractor Address <br />CA Lic # Class <br />Insurer -� ri;'l6 <br />Work Comp <br />T ICC Technician's Name Expiration Date r <br />R IGC Installer's Name <br />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/Z, etc.) Installed <br />T <br />A <br />N <br />AV <br />P ❑Approved El Ar with conditions El Disapproved <br />q(See Attachment With Conditions) ---- <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL <br />THE jbAQUINJCRMANCE ENVIRONMENTAL <br />WOR WORK IN ACCORDANCE WITH SANJOAQUIN COUNTY R OR LICENSED GENT'INANCES, STATE LAWS, AND S SIGNATURE CERTIFIES THE FO�L'AND REGULATIONS OF S]N, <br />OF AWING, I CERTIFY -THAT <br />05 OR WHICH ED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNERSTO BEGOMESUBJECT HOAR IN THS E PERFORMANCEOF THEW ORNASRP ONTRACERMIT IS TOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES fi $ FOLLQWING '_"ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALCEMPLOY PERSONS SUR IECT,TO WQRk I CERTIOF'CALIFbRNIA."' ER'S COMPENSATION LAW <br />_ . ... <br />Applicant's Signature Titie <br />Date <br />BILLING INFORMATION: <br />Indicate. the responsible. <br />party to be billed for additional EHD staff time expended. beyondeermit pamenP t cov$rage per tank. f rmit applicant e.g. property owner, the for the billnIparty must acknowledge' this <br />below. <br />NAME L�t�E_Ly �T��-i TI "Si �"i°JPHONE #���/ <br />��St � tD <br />ADDRESS <br />Al <br />SIGNATURE' ° <br />DATE C , A I <br />EH230038 (revised 08/1/11) - <br />_ CCT 2 4 2014 <br />a <br />,r � � H <br />