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•, 1 A t A r ri * A d e'`P t �-` <br />Fes._ / t'idYi 4..#8P # t tr NtC A�*: �+Fd -i. 9- 1 ♦ PA /. A !'. M° x�; <br />t 4, r ♦Y r♦ r 1♦ N#♦ ItT a, P1 _ <br />y5'Y W P+ <br />Irtydh"1 <br />!, <br />i • q.. , <br />is r a <br />EiENVIRONMENTAL' <br />NVI ONM NTALHEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />I 600 East Main Street, Stockton, California -95202 <br />Telephone: (209) 468-3420 rax f209) 468-3433 <br />` <br />APPLICATION FOR UNDERGRdUND STORAGE TANK <br />RETROFIT -OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYP <br />11E BELOW; <br />TANK RETROFIT ❑PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F EPA Site # <br />A __. Project Contact &Telephone.#. <br />O Facility Name <br />Address Phone t2 9 <br />c3 <br />I <br />T Cross Street <br />Y Owner/Operator <br />G Contractor Name Phone # <br />0 <br />NContractor Address Phone# <br />T <br />A Insurer CA Lic #I"7l� Class�,•�� <br />GICC Technician's Name Work Comp # <br />T _ <br />R ICC Installer's Name Expiration Date <br />Expiration Date <br />Tank system work area <br />(i.e. 87plping sump, 81 leak detector, UDC 1/2, etc.) Tank Size Chemicals Stored Currently Date UST <br />T <br />Installed <br />A <br />N <br />K <br />LApplicaffs <br />_ <br />Approved proved with conditions <br />(See a ment With Conditions) El Disapproved <br />lan Reviewers Name <br />Date _2 <br />T MUST PERFORM ALL WO N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />,COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN <br />ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED_ , i SHALL NOT EMPLOY ANY PERSON IN SUCH A_MANNEft.AS.TO BEGOMEY THAT <br />SUBJECT IN <br />HE PER ENSATION LAWS OR CALIFORNIA " CONTRACTOR'S HIRING bR SUBCONTRAGTIN� SIGNATURE CERTIFIES THE FOLLOWING: "i CERTIFY <br />HEPERFORMANCE OF THE WORK FOR WHICH THIS PERMIT,($ ISSUED,,.) SHALL EMPLOY PERSONS SUB IECT,TO WORKERS CQIPE <br />NSATIO <br />N"LAWS,, ., <br />RSignature <br />nea Pr�rvrrkilry®`N /w _ /(JI d'I®s r-� <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 art designated below is different than the permit applicant, e.g, property owner, the party must acknowledge this <br />Party g <br />responslbilltyforthe _billing bysignature and.date elow. <br />tri(t}I Ct , <br />NAME Iori .. .. _..._.. <br />--�_TITLE�It'.PHONE # <br />ADDRESd - _. i <br />SIGNATUR—(� — <br />E <br />DATE <br />EH230038 (revised 08/1/11) <br />l <br />