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• <br />0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY CINE <br />1868 E. Hazelton Ave., Stockton, Califomia 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 JAN 0 5 2015 <br />APPLICATION FOR UNDERGROUND STORAGE TANK r=NVIRONMENTAL <br />RETROFIT OR PIPING REPAIR PERMIT ,r?,,«, -,..r-?: nTe*,cw,IT <br />THIS P RMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />C TANK RETROFIT (PING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/M UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # U <br />C <br />Facility Name i Phone # SIR& 17K7 <br />Address <br />Cross Street berviln <br />y <br />Owner/Operator �� (' <br />Phone# _ 1 <br />c <br />0 <br />Contractor Name <br />Phone # <br />N <br />T <br />Contractor Address -7' ,) W C <br />CA Lic # 6ITClass <br />R <br />A <br />Insurer <br />V� <br />Work Comp # <br />TICC <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. er piping sump, 91 leak ae�a«, UDC 1n, e(c.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />1 OD <br />n <br />t <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers NameAq-1� Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LANS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY <br />AT IN THE PERFORMANQE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.` <br />Applicant's Signature Tflle1�.-- <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 >� , t et &e t & lb 1100, TITLE rn.A-J �f,�xk r PHONE # TU,- - -7 <br />EH230038 (revised 07-17-2014) <br />K <br />