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+ . r ♦ i � w ' t + w ) ' roti" t- a�Y " '�?�"w t : i w / r w ► •' ' v + �w . w ' .� �� i - t i. � � .� 1t�it wr + w♦ i w } +� ..": Tri;+ `it , +y � i i ► ► �ti+ .fiir yw �►'. � i � ► . + , ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE F I EPA Site # A C Facility Namefbc :�- Address C l o 16 eoxw I Cross Street T Y Owner/OperatorPot C C Cantractor Name - �col N T Contractor Address yy�� R A Insurer'L,LL4L"t L_ C T ICC Technician's Name o R ICC Installer's Name Tank system work area (i.e. 87 piping sump, 91 leak detector, UDC l iz etc.) T A N K P ❑ Approved L A N Plan Reviewers Name / Project Contact & Telephone # Tank Size OJApproved with conditions Attachment With Conditions) ❑ Disapproved 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THATIN 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 N/ORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF' CALIFORNIA." _ �7 Applicant's Signature Li `I111t )Y1 TA��P�PrvWcoYklli�ikip'N BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAMXDCJ TITLE DPHONE # 2f- �Lu � ADDRESS SIGNATURDATE EH230038 (revised 08/1/11) 2 Phone # R Phone Phone # CA Lic # Class Work Comp # , Expiration Date Expiration Date Chemicals Stored Currently Date UST Installed OJApproved with conditions Attachment With Conditions) ❑ Disapproved 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THATIN 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 N/ORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF' CALIFORNIA." _ �7 Applicant's Signature Li `I111t )Y1 TA��P�PrvWcoYklli�ikip'N BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAMXDCJ TITLE DPHONE # 2f- �Lu � ADDRESS SIGNATURDATE EH230038 (revised 08/1/11) 2