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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (269) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE- INDICATE PERMrr TYPE BELOW <br /> ❑ TANK RETROFIT ElPIPING REPAIRIRETROFIT R3 UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# C a-36 41A-PD0 <br /> C Facility Names4X) tlIA,i CQt� JIU13UC WD4<5 —CC 1Y .1 Phone# <br /> Address LW C' <br /> I Cross Street I Gst,h,1 LL) <br /> T <br /> Y Owner/operator Sj C,0 PV&I c U-)t3ILA.5 Phone d q -- d <br /> a Contractor Name �j �L �� l�iJ �� . Phone ;Z� 36 7- 4 f, OO <br /> T Contractor Address,� M U G +' G CA Lic# 7J C Clas Q , a <br /> n Insurer Al� � C MUD 144.6 I4,� Work Camp# WcvAJ 00 q20 cf 7 D/ <br /> G <br /> r ICC Technician's Name (]f L('/y, r L) r Expiration Date ///,Pr20,(C,) <br /> iCC Installer s Name Ex Iration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump-91 leak detector,UDC 112.etc.) Installed <br /> A <br /> N <br /> K <br /> P �� Approved Approved h conditions Disapproved <br /> L {See Atka me I ondit' ns} <br /> A / q <br /> N Date er f ��6 <br /> Plan Reviewers Name [ <br /> APPLICANT MUST PERFORM ALL WORK! AGC DA E WITH SAN JOAQUIN CO TY RDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL H LTH EPARTMENT. OWNER OR LlCENS D ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL T EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu Title 4ate 't <br /> BILLING INFORMATION: ' <br /> (ndicate 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. <br /> NAME S C TITLE rN PHONE ia <br /> �� r&)(� <br /> ADDRESS ,2 *Ae go <br /> SIGNATURE DATE <br /> EH230038(revised 021 ) <br /> I <br />