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0 • <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 # <br />� <br />Facility Name QM, <br />W,--:4 <br />Phone # <br />� <br />Address 3250 <br />E 2 E <br />TCross <br />Street / S <br />Y <br />Owner/Operator <br />Phone # ?43-31OZ51c, <br />C <br />Contractor Name <br />Phone # �79-Q <br />0 <br />N <br />Contractor Address —i�p <br />�J�-/� <br />CALic# 3-/ 75 Class 14 -,6_C../D <br />T <br />AInsurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name <br />5U <br />Expiration Date /D-ZL7 <br />R <br />ICC Installer's Name <br />yo per(/ <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />with conditions ❑ Disapproved <br />L <br />___N::Shproved <br />(Se achment With Conditions) <br />A <br />N <br />; �/'- <br />Plan Reviewers Names` <br />2 <br />Date tJ // / <br />5h/ <br />oz <br />APPLICANT MUST PERFORM ALL ORK 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 <br />IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFOR E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFO <br />AIDDlicics <br />Si ature ff <br />Title Date - <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. <br />NAME_ OS _TITLEW/(/�1L1%G�E'J� PHONE # / p c <br />ADDRESS <br />SIGNATURE �y%i1 _ DATE <br />EH230038 (revised 08/1/11) <br />