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ENVIRONMENTAL HEALTH DEPARTME�-Nj-. <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 MAY 5 2016 <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 18D 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 />Facility Name �, r Phone #, <br />L <br />Address <br />I <br />Cross Street <br />T <br />Y <br />Owner/Opera <br />Phone # <br />c <br />Contractor Name <br />Phone # aca <br />N <br />T <br />Contractor Address ) t �� �� CA Lic # Class C <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name, <br />pu <br />EExpiration Date Lk <br />° <br />R <br />ICC Installer's Name <br />on Date <br />Tanksystem work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />4i.e.87 piping sump, 91 leak detector, UDC 112, etc.) <br />, <br />T <br />A <br />K <br />P <br />❑ Approved XiApproved with conditions ❑ Disapproved <br />L <br />See Attachment With Conditions) <br />A <br />N <br />f)'110 ® —010 <br />t <br />Plan Reviewers NameloDate <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRON ALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF T WORK FO WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENS ON LAWS OF CALIFORNIA." CON R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERF ANCE OF TH ORK FOR THIS PERMIT IS ISSUED, I SHALL LOY PERSON SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." Nr�'W Ud <br />--- ..-�.--_ —_,., Tula Date <br />R <br />BILLING INFORMATION: <br />Indicate the resp sible a y t e billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designate 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. "j 7� <br />NAMEC ( __ i t <br />TITLE E # <br />XG <br />SIGNA <br />EH230038 (revised 1 <br />PA <br />TE '�' 'i _ <br />Ii <br />