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1 ' <br />ENVIRONMENTAL <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 469-3420 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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F -EPA-Site # Project Contact &Telephone/#j Phone ' , - <br />C <br />Facility Name - %'1 G Qi/1%ild° # f `T — <br />Address <br />TCross Street <br />Y Owner/Operator Phone # '174 - /c? J7 <br />C Contractor Name <br />O - — - Phone # <br />--- <br />N Contractor Address CA Lic # lJO Class&6 <br />T <br />A Insurer Work Comp # O 9 <br />r <br />-:C. ICC TechniclansName-..,:_.. -Expiration Date- - <br />RICC Installer's Name Expiration Date <br />Tank system work area Tank Size Chemicals Stored Currently. Date UST <br />(.e.'87 piping sump, 91 leak detector, UDC 12, etc) Installed <br />T <br />A <br />N <br />K <br />P 0 Approved proved with conditions Disapproved <br />L (Sachment With Conditions) <br />A Al <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />SHE -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 />TH9 - IN THE.PERFOR CE OF THE WORK FOR WHICH THIS PERMIT.I5ISSUED, (SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA _ <br />AnnliranYs:Sianature - V Ui l 1.... �/ A J%• ! / Yi %�i��14 Rata 4,111t I OR—AW - - - <br />inA{Icate the responsible party to be billed for additional EHD staff time expended beyond permit payment cover -age per <br />tankIf the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this res sibility for the billing b signature and date below. <br />NAME / TITLE // IG¢%iQ PHONE * 40/7-6337 <br />ADDRESS C ✓215 l� ll fi'o /kywA <br />2 <br />