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0 <br />• <br />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 <br />EPA Site # <br />Project Contact & Telephone #90.S 6 !1owL,. <br />� <br />Facility NamePhone <br /># Qto �� Q <br />L <br />Address 1519 <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # 2,5 "to 61100 <br />C <br />Contractor Name <br />Phone #9QS�p- (a <br />0 <br />,%60 <br />N <br />Contractor Address �. <br />CA Lic # 4M —16 %S Class <br />T <br />AInsurer <br />'' Work Comp #0 Ls A— <br />C T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak' detector, UDC 1/2, etc.) <br />Installed <br />Oa <br />T <br />/ <br />N <br />(� Q o <br />I1 <br />K <br />QQ <br />ti <br />P <br />❑ Approved <br />pproved with conditions ❑ Disapproved <br />&chment <br />L <br />(Se With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />V �z <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SA QUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF OR WHIPPERMIT <br />IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPEN ION LAWS CAL ORNI <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN <br />THE PERF MANCE OF TH FO <br />ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />, <br />' i� A 1 <br />Applicant's Signatu <br />Title Date ` v <br />_/ � % <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 four the billing by signature and date below. c 'a r <br />NAME Cj`ii. 11 TITLE x PHONE# C� `QJ • 4 `6 '7�C74 <br />ADDRE <br />SIGNA <br />EH230 <br />to <br />N— <br />