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"ENVIRONMENTAL HEALTH DEPARTIf <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 AU,G 0 9 20,113 <br />Telephone: (209) 468-3420 Fax, (209) 468-3433 F <br />rV E <br />APPLICATION FOR UNPI`RGROUN D STORAGE TANK <br />-EN1' <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 181} DAYS PROM THE APPROVAL DATE. INt9ICAW PERMIT TYPE BEI -OW: <br />[1 TANK RETROFIT D PIPING REPAIR/R OPIT O U. tR�I�, IR/R0, i`RQPIT to COW <br />p TARTIEVR UPGRADE <br />F F -PA, $ita # Pfoie0 0.antact 8s Tolo.phane <br />C Facility Name arMi 1 Thane # <br />L Address ., 70 ti,1 <br />T Cross Street <br />Y Owner/Operator ,pt, j Phone # <br />o Contractor Namej.V A Rhpns # S ► k414 ' 17 <br />T Contractor Address $S? K). IJ l t -i (O CA Lip # T-6'7 Class A N°r <br />A Insurer �t a t Work Comp # <br />-. <br />T ICC Technician's Name Exp+rstEon Date <br />ICC Installer's Name Expiration Date <br />Tsnk system work area. Tank i p Chemicals Stared Currantl Date UST <br />(L9, 07 piping sump, Rt KBOK d®tsctvr, UPO ilk, aid Installed <br />T � � FI t-<— <br />A <br />N <br />K <br />P I ❑ Approved M AAppmved with r„pndiiions . Q Disapproved <br />(See Attachment nth Conditions) <br />N Plan Reviewers Nams Date _ r _ <br />?LICAN'r MUST PERFORM A" WORK IN ACCORDANCE WITH SAN JOACIUIN COUNTY ORPiNANCES, STATE LAWS, ANO RULES AND REOUI-ATIONS OF $AN <br />QUIN COUNTY, ENVIRONMENTAI, HFAI;TH W-ARTM$NT: OWNER OR LICENSED AS F,1117 p^ SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />PERFORMANOI: OF TME WORK FOR WHICH THIS PERMIT 15 18$UED, I SHUN NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BC -COME EVIBJECT TO <br />RKER'S COMPENSATION LAWS OF CALIFORNIA.,." OONTRACTOR'S HIRING OR SU16CONTRACTING SIGNATURE GERTiFiRs THE F04LOWING: "t CERTIFY <br />IT IN THE PERFORMANCE OF THE WORK FOR WHI THIS PEaMIT I81$50HI7, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'E COMPENSATION LA" <br />�f � ILLING INFORMATION: <br />Indicate the MspariMble Psrty to be billed for @ddli gnall EHR slaff tires 09,anc.led beypnd parrnit payment coverage per tank. If <br />the party designat$d below is different thsn the permit spp(ltgrlt, e,9, property kwnor, the party mypt acknowledge this <br />responsibility fpr the fulling by signature and date below. <br />NAME SC'�>r 5` IT1, �t�Nid AC-'Cc-� PHONES <br />0 <br />EH230039 (revised <br />2 <br />