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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 JUN 2 2 2016 <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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 2 <br />A <br />C <br />Facility Name �� Jr ,� B/ rnJC <br />Phone # - <br />Address , <br />1 <br />Cross Street L� <br />T <br />r <br />Y <br />Owner/Operator e2 <br />Phone #2-o <br />o <br />Contractor Name "� �- lC <br />Phone # <br />N <br />T <br />Contractor Address <br />CA Lic # �6Class f; j( <br />AInsurer <br />A;�y rr <br />Work Comp # r <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area Tank Size <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />A <br />�� ~ <br />LIE 4 <br />N412 <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />LAttachment <br />A <br />With Conditions) <br />NPlan <br />Reviewers Name Date _ R46 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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 HE W THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Z / <br />Applicant's Signature Title624�,:FADate <br />v L 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 billingbysignature and date below. <br />NAME J/M TITLE PHONE # 21r7 611 <br />�—/ �✓o,,�sf AEC, <br />SIGNATURE <br />EH230038 (rebiSed 12-yi-15) 2 <br />cqe- 5s z -�e/ <br />