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0 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <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 /> D TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A _ <br /> D Facility Name � b "C t1,�} l� ( + /�1`�tr1�t� �-l_. (�, Phone# �L� ... S(p (p L <br /> L Address G� ° c)A D <br /> T Cross StreetLl <br /> �t <br /> Y Owner/Qperatoi2!�,0'1' `t(ZAj -{„� CF 1,3 1 F- � 1_ri 0 Phone# e �(<,o�~ C p c� I O <br /> C <br /> contractor Name �� Giat} C �Ot1tiQ i h Phone# <br /> N Contractor Address 1~,t 1Cr�1S 2ttrtci� lcj '1 CA tic# Class <br /> T 1 Qq v u�uEvwv, <br /> A insurer"t �i 1�?tJ {, l N5J 2A 11G�L �Ob�f11�A" Work Comp# 1001 b <br /> Technician's Name <br /> T ICC ThI et Vo��..'zj$1 1'1_ uDh i Ct+'1 G-'t U 1'`4'L(�,"Z" Expiration Date S;/ <br /> 3 p Zo t <br /> R ICC Installer's Name I��t 6013\f L ��� t `�, Expiration Date 18 3d Z�! <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e.87 piping sump,91 leak detector,UDC IR.etc.) Installed <br /> T <br /> A <br /> N - - <br /> KOil V k— <br /> AUG <br /> s) <br /> 4 i.-Lam' <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name_ <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. "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 /> WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THEP MANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED,t SHALL EMPLOY PERSONS SUBJECT TO W?RKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicant's Signature � fA AA Date 08/05/2016 <br /> (k/vvvv-?--r`7- 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. //t� , n (�(�[� (� <br /> NAME 6U-- �j�1. TITLE -A 121A l IJ. PHONE# 69)- `Z 7 Z ?0 3 1 <br /> ADDRESS 1. f1�1 ; I�C�p'�bjVl� 1 1�1 �-1 (J <br /> SIGNATURE , DATE 0-8/05_ /�6 <br /> EH230038(revised Z-1 1-15) 2 <br />