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RECEIVED <br /> : ' ( I I Environmental Health �p aftr r�� Ifl <br /> C O U N T Y - <br /> HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TAV6CN11/ IITA <br /> i� F1=AI g � 4 NT <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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Mpgan Mitchell _ 6137 <br /> C Facility Name I Dorado Gas d Phone # 09-939- 6 - <br /> I <br /> L Address 1605 S El Dorado St Stockton Ca 95205 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Angle Phone # 209-939- 1906 <br /> o Contractor NameMegan e l Phone # 209- 6 - 7 <br /> N Contractor Address CA Lic # 1001331 Class <br /> T - <br /> n Insurer Midwest Employer CasualtyCompanywork comp # <br /> Q <br /> T ICC Technician 's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date,_ 12,02"o <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 /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CWR7CC R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI }(THIS PE MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Date <br /> LING INFORMATION : <br /> Indicate the responsib a party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME_Mpclan Mitchell TITLE.Office Assistant PHONE # 209.461 .6337 <br /> ADDRESS <br /> SIGNATU E1A A DATE 9/ 1 /2n2 /1 <br /> 2 of 6 <br />