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0 10 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RE.CEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 MAY Q r; 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK > WALFH <br /> L <br /> RETROFIT OR PIPING REPAIR PERMIT , ERIA <br /> rr/SC <br /> `bE <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# .(. y utd <br /> � Facility Name coCL GWO <br /> i e AVO � 33 Phone# <br /> I Address ( w—,w- ' c �GVAOr,4 (!A g <br /> L <br /> I Cross Street <br /> TPhone# teab L3 ro <br /> Y Owner/Operator GmrqwD <br /> oContractor Name b� ` cIki LL �L, Phone# <br /> N Contractor Address I`p CA Lic#,�fi�� �C.�- Class�l��C.id Z <br /> T <br /> AInsurer � �t-C Z t Work Comp# ®� <br /> T ICC Technician's Name ��, � Expiration Date AD(9 <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K VV V <br /> P ❑ Approved [� Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> a <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUN 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: "1 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" 1( , <br /> Applicant's Signature V V Title 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 anddatebelow. COW <br /> N � j l ^3 t <br /> NAME 1�1 -i LJ V S 6) KA-A TITLE W ye �(KX PHONE# c"'�`p[1-3— <br /> NAM <br /> .l— <br /> CA -1, arc� r�-- <br /> ADDRESS UL tl�--j�� "'E,/ JLC til, �!0`art" i y <br /> SIGNATURE I�A Q I dUa E1-L.- �-- DATE �l,3)tU <br /> EH230038(revised 7-26-2016) 2 <br />