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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 /> D TANK RETROFIT o PIPING REPAIR]RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # avk j- U. vLl ; L ''�© ��'�' ( <br /> C Facility Name r" pp � `c � � �C1D 3 � p Phone # <br /> L <br /> Address ( oZ tO -� QLt <br /> � UALImo <br /> I Cross Street <br /> T Phone <br /> Y Owner/Operator U a p GV�V C C i,r �• L <br /> C Contractor Name f-Y6 � ` � � VI ,' LI LLLew IV Phone # <br /> Q • 401- 4'� 13 , A'� Ct0 (4AI <br /> N Contractor Address ���, co CA Lic # Class <br /> R Insurer , &IL c�t)-SUL — Work Comp # Q � � <br /> A <br /> c ICC Technician 's Name ( .- ttr�.cc �1 �t- 1 Expiration Datecj ©( �( <br /> T <br /> R ICC Installer's Name Expiration Date <br /> Tanks stem work area Date UST <br /> y Tank Size Chemicals Stored Currently Installed <br /> (le, 87 piping sump, 81 leak detector, UDC 1/2, eta) <br /> T <br /> A <br /> K <br /> NINE <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> N Plan Reviewers Name <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 AGENTS 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 /> AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> WORKER'S COMPENSATION L <br /> THAT IN THE PERFORMANCE A THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature <br /> .•u-,�, v . �P.�G��VTitle `�:�. � L' 1. uE' ��GtL S � Detb "`� Z �' 1 <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 /> responls� iJbility for the` billing Ib1y�signatuurre�and date below. , / �(�� �Q <br /> NAME HAwl d V ` v" � L4 � ��� TITLE ` lJ e PHONE <br /> ' " - ' � � � ^ ` - <br /> ADDRESS . - At L p <br /> c DATE <br /> SIGNATURE�t +,4"1 <br /> EH230038 (revised 7-26-2016) 2 <br />