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rd. a <br />Nl <br />i r <br />i <br />Ar <br />d MY Y Y ri Y Y «�+Y NY nx A..�d•.� dd Yd i 1 <br />d <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />N SAN JOAQUIN COUNTY <br />600 East Main Street,_ Stockton, California95202 <br />Telephoner (209) 468-3420 rax: (209) 468-3433 <br />APPLICATION FOR UNDERGRdUND 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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F EPA Site # Project Contact & Telephone <br />O Facility Name Qu, m ao het Phone # I <br />L Address <br />I Cross Street <br />Y Owner/Operator np kj' (�'1 Phone 1Gs <br />C Contractor Name <br />o Phone <br />N # <br />Contractor Address <br />T CA Lic # Class <br />R Insurer <br />A a Er <br />ork Comp # a r` <br />T iCC Technician's Name <br />piration Date <br />RJCC Installer's Name <br />pirDate <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.) y Installed <br />T <br />A <br />N <br />K <br />P ❑ Approved pproved with conditions ❑ Disapproved <br />A G(Se ttachment With Conditions) <br />N Plan Reviewers Name_4X,.,__ <br />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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 SUB00NfRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN E 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 C 1f'tiYP FP il'�'1� i �Ir n . " ' "/ — t 2, <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. <br />NAME F IrTE.ID i°�nTRi>c�tI 'nmb TITLE tx� _PHONE# <br />ADDRESS. _ .0.1 1L ► P.IV MW�CTt- <br />SIGNATUREDATE_ <br />EH230038 (revised 08/1111) <br />Y IY <br />N <br />