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ENVIRONMI N-TAL HEALTH DEPARTMENT _ __ JOA - C 600 East Main Street, Stockton, California 95202 Telephone: (209) 465-3420 Fax: (209) 465-3433 X10 qP — Tank system work area Date UST (i.e. 87 : 91 UDC 1/Z �> Tank Size Chemicals Stored Currently. Installed T A N K P ❑ Approved Approved with conditions ❑ Disapproved L ( A ant With Conditions) -N Plan Reviewers Name . _.......•. — -- Date ------ — APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN --.-T+IE-PERFORMANCE.OF'niEMORK=FOR-WHICH-THIS-PERMIT IS -ISSUED; -I SHALL-NOT-EMPLOY-ANY-PERSON-IN-SUCH-k-MANNER-A;S?O-BECOME-SUBJECT- - TO WORKER'S COMPEN TION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFO5MAIjCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS' OF CALIFORNIA.". ��/ J% Applicants Sign8ft" W_I.� Tile OdUaate BILLING INFORMATION: Indicate the responsible po party to be billed for additional EHD stafftime expended beyond permit payment coverage per tank. If the party designated below is d'Ifferent than the Dermit aDDiicant. e.a. Drooerty owner. the Darty must acknowledge EH230038 (Lei ised 07rMl0) 2 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE F- -EPA Site # Project-Contact&Telephone # I� A C Facility Name �j Phone # I K �' 7 L Address la33 ` I Cross Street Y Owner/OperatorVl-aDia Phone # Contractor Name 5 Phone # T Contractor Address r, ICA Lic # Uo&17 Class&6 A Insurer Work Comp# T....... JCC -_Technician s Name- _Expiration:Date . _ R ICC Installer's Name Expiration Hate X10 qP — Tank system work area Date UST (i.e. 87 : 91 UDC 1/Z �> Tank Size Chemicals Stored Currently. Installed T A N K P ❑ Approved Approved with conditions ❑ Disapproved L ( A ant With Conditions) -N Plan Reviewers Name . _.......•. — -- Date ------ — APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN --.-T+IE-PERFORMANCE.OF'niEMORK=FOR-WHICH-THIS-PERMIT IS -ISSUED; -I SHALL-NOT-EMPLOY-ANY-PERSON-IN-SUCH-k-MANNER-A;S?O-BECOME-SUBJECT- - TO WORKER'S COMPEN TION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFO5MAIjCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS' OF CALIFORNIA.". ��/ J% Applicants Sign8ft" W_I.� Tile OdUaate BILLING INFORMATION: Indicate the responsible po party to be billed for additional EHD stafftime expended beyond permit payment coverage per tank. If the party designated below is d'Ifferent than the Dermit aDDiicant. e.a. Drooerty owner. the Darty must acknowledge EH230038 (Lei ised 07rMl0) 2