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ENVIRONMENTAL <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 OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT ❑ OLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> Lk3377- <br /> A <br /> D Facility Name QLt �- Phone# <br /> � Address 34905.` Ch-615kan <br /> TCross Street <br /> Y Owner/Operator s Phone# ` <br /> C Contractor Name <br /> Phone# <br /> N Contractor Address CA Li # ��7 lases®!J - <br /> T W 6°C y <br /> AInsurerWork Comp# <br /> T ICC Technicians Nam Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 AGENTS 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM69-CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Z <br /> Applicant's Si9�et�re ;ne C C� Q!1 CC D <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this resnsibility for the billing by signature and date below. <br /> NAME t®_ 11 ' I TITLE 6i(t C /2`( ✓tPHONE# l <br /> ADDRESSLy <br /> (, <br /> SIGNATURE DATE__ <br /> EH230038(revised 07/22/10) <br /> 2 <br />