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� r3 <br /> ENVIRONMENTAL ALT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT IPI G REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# /� <br /> A <br /> C Facility Name � � ��'� / Phone# 571,j"' 7, Z-1y Z <br /> I Address <br /> TCross Street <br /> Y Owner/Operator Phone# - <br /> c Contractor Name Phone# ��'�� VS' 71 <br /> TContractor Address �,e�, 5' CA Lic# 00 <br /> R Insurer Work Com # <br /> A �y'� yrs' � p e) / 7Z-71-7-7 <br /> TICC Technician's Name C-Ar, �e v ve 7 Expiration Date <br /> R ICC Installer's Name .Urfa 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 /> P ❑ Approved DApproved with conditions ❑ Disapproved <br /> L ee Attachment With Conditions) <br /> N Plan Reviewers Name Date e2 I <br /> APPLICANT MUST PERFORM ALL W 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Date Z— <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. -707 <br /> � <br /> NAME_ _% C✓ �f �f ,C— 2 <br /> TITLE 74,tv PHONE# ���J �! d <br /> ADDRESS �r /�v !%4.- .� "✓�L.s �� <br /> SIGNATURE DATE ` <br /> EH230038(revised 08)/ <br /> 2 <br />