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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <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 REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # «L _� _ �� <br />Project Contact & Telephone # <br />G <br />Facility Name <br />Phone # <br />�Address <br />L> <br />T <br />Cross Street u_lk <br />Y <br />Owner/Operator <br />Phone #a09 - k(-7 <br />C <br />Contractor Name 1�� L�� �C31 ��p� . i16�� <br />Phone # - `j S7- 9"-z, <br />a <br />N <br />T <br />Contractor Address 91_� j f�(�I L� p (] �/� <br />CA Lic # %3%3.;-)O S Classcrof D(�/O <br />A <br />Insurer (,�}qv S(� l� �(���,(� WV_ (Tc I tJS • C0 , <br />Work Comp # � o z o <br />TICC <br />Technician's Name LU (S <br />Expiration Date <br />Q <br />R <br />ICC Installer's Name L_U (S <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />TLS � 5D t10t-1TT- CZ4t SG <br />N <br />�uSTc�irYl <br />(� CitsO lS (� / (Z�G <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />( tachment With Conditions) <br />A <br />N <br />Plan Reviewers Name _ Date 66 <br />APPLICANT MUST PERFORM ALL WORK IN ACCO 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 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br /><171 <br />— m <br />�� T' <br />Applicant's Signature Rle 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 l PmRP,6`y S 1 1�A I LL0 �'j TITLE C' W� �` PHONE #� <br />os7 5�_ c. c bra od S► . <br />EH230038 (revised 10/30/12) <br />Kd <br />TE_9- 27^-13 <br />'-Z <br />