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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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name LOTS, L Phone# f)(}() -- `,j(aa- 0 <br /> � Address El®t epo A D <br /> TCross Street , a( <br /> Y Owner/Operators[`0 j' `F j e4_._ C_5 I,3—pp- # j) <br /> o Contractor Name ,®�1�h � ( -v,,2j Q� Phone# 90q-Z 3 9--7 Zig 5 <br /> T As 12 <br /> Contractor Address Q5+ Lt1C ,InC41 i . CA Lic# 8M' bl Class .(A7, <br /> R <br /> Insurer"' A��i�L l 0SJ4 �0rPA Work Comp# l QD (� <br /> T ICC Technician's Name ( QO'j„°�j`l l 7- doh j Ct V\ G�rf �Z Expiration Date 3 [7-ovi <br /> R ICC Installer's Name I�t� �d� L ���� �J`� Expiration Dates <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.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (XeAachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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: N 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THEP MANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO W RKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. <br /> Applicant's Signature�L- Title flVvl& Date <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 tth�e,billing by signature and date below. <br /> NAME 6 rI V�- TITLE �f^t D M l(�' PHONE# 00 <br /> " `(��6y <br /> L—Q7 S 1 <br /> ADDRESS 940 �, . Q C �d tf'�P" �Ci�� W( P r It 1 (� O <br /> SIGNATURE DATE Z W <br /> EH230038(revised 1(11-15) 2 <br />