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40 <br />~ RECENED <br />ENVIRONMENTAL HEALTH DEPARTIM&82009 <br />Ni HEAT TH <br />SAN JOAQUIN COUNTY PERWOERVICES <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK 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 # <br />A <br />Facility Name tCU osLTSU <br />Phone #C C/(a iZ -( (o/-7 <br />� <br />L _--- <br />Address _1(p l `1_ tJ /-em GYt> ._ 34( L" _ C!4 <br />T <br />Cross Street <br />Y <br />Owner/Operator a kc o <br />Phone # <br />CContractor <br />Name IZ <br />Phone #1 <br />N <br />T <br />-- <br />Contractor Address W L/L' 3` 7- 3 <br />///O- <br />CA Lic # Class <br />------ ----- <br />R <br />A <br />------- ------ <br />Insurer ! �� 1 <br />Work Comp # <br />- - - --------- <br />c <br />T <br />ICC Technician's Name �" <br />f G1 � Z S i y -� Lj <br />Expiration Date 5-2,3-11 <br />p <br />Q <br />R <br />_ <br />ICC Installer's Name <br />Expiration Date <br />^ Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump. 91 leak detector, UDC 1/2, etc.) <br />T----- <br />----- <br />— <br />A <br />N <br />K <br />- <br />P <br />Approved Approved with conditions Disapproved <br />L <br />A <br />Attachment With Conditions) / <br />I� <br />N <br />AUG <br />Plan Reviewers Name-�----------_-__ e_ _ <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA,' <br />Applicant's Signature_ Title Date <br />BILLINU INFUKMA I IUN: <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. <br />ADDR <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />TITLE PHONE # <br />1 <br />DATE <br />