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1 ; ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 P ❑ Approved ,Approved with conditions ❑ Disapproved L (See Attachment ith Conditions) A N Plan Reviewers Name q/zol2 Date �PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OR CES, STATE LAWS, AND RULES AND REGULATIONS OF SAN )AQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE.CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN IE 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 ORKER'S-COMPENSATION LAWS OF cAUPORNIA. CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY IAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS, = CALIFORNIA. n�C1plicant's Signature Title � Date ' BI LLINO .INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signatur4 and date below_ . / Incj4 `tjllTTLtE [� ...... _PHONE # ♦ ADDRESS SIGNATURE `�� DATE EH230038 (revised 08/1/11) 'f I'`•`,"". a^. ; t t .. ♦a{{ r.. �:,�� .,u� ,t,, t + ♦ 4 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE F A EPA Site # Project Contact & Telephone # _I C Facility Name au Phone # I L Address 5 T Cross Street r r Y Owner/Operator L4 Phone # tU Zr o Contractor Name sm Phone # T Contractor Address 26M.10CA Lic # Class R A Insurer Work Comp # 1686 c ICC Technician's cians Name Expiration Date `�-�K-3� R ICC Installer's Name Expiration Date Tank system work area Tank Size Chemicals Stored Current) (i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) y Date UST _ Installed T A N K P ❑ Approved ,Approved with conditions ❑ Disapproved L (See Attachment ith Conditions) A N Plan Reviewers Name q/zol2 Date �PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OR CES, STATE LAWS, AND RULES AND REGULATIONS OF SAN )AQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE.CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN IE 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 ORKER'S-COMPENSATION LAWS OF cAUPORNIA. CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY IAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS, = CALIFORNIA. n�C1plicant's Signature Title � Date ' BI LLINO .INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signatur4 and date below_ . / Incj4 `tjllTTLtE [� ...... _PHONE # ♦ ADDRESS SIGNATURE `�� DATE EH230038 (revised 08/1/11) 'f I'`•`,"". a^. ; t t .. ♦a{{ r.. �:,�� .,u� ,t,, t + ♦ 4