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Jun, 11. 2014 9:42AM <br />No. 4258 P. 2 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 952058 EC E I VE D <br />Telephone: (209) 468-3420 Pax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK JUN 112014 <br />RETROFIT OR PIPING REPAIR PERMITENVIRONMENTAL HEALTH <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. Q�-� SCA �-r <br />❑ TANK RETROFIT [i PIPING REPAIR/RETROFIT ,(UDC REPAIR/RETROFIT ❑ COLD STAR "Q�IM <br />F <br />EPASite# �A(�d�dL�j p(a <br />Project Contact&Telephone# 6AA1j0o,,j S,M1TI1 i1� ��-571 <br />C <br />Facility Name C 14Fjf 64 A' 367 76� <br />Phone # Z,v? . 4.!�?_ -7Z)3 <br />I <br />Address q(_KCuAy srdcK'rd� cA. <br />r <br />Cross Street C- )6,q -r MI Lg! &AD <br />Y <br />Owner/Operator C /4 f,/ t -6,0 <br />Phone # L<- 0`17- - 11 D <br />C <br />Contractor Name (Uf�y,cJ� �J�'�/Zy <br />Phone# <br />T <br />Contractor Address .30 lvlAI1t1 Vf 6ACo,j j �A, <br />CA Lic# pp -3 Vs' Class' o�1v N �c3 <br />A C2,4 a _ c <br />Rnsurer <br />A <br />,1 <br />I�D ;/�f- �,c11�//LA,V� Gds f}.J <br />Work Comp #,--, yy ?Z 7 Z Z7 <br />ICC Technician's Name ,pdA)4 WO eA tM1 A) I <br />T <br />Expiration Date -Z. -I <br />R <br />ICC Installer's Name �lJ�4�•►� �'}t)GJ1 Expirafion Date 9-)V-16 <br />Tank system work area Tank Size Chemicals Stored Currently Date UST <br />(I.e. B7 piping UKV, 91 Ir4K defector. UDC la etc.) Installed <br />T <br />906ULACL <br />-,201660 <br />CA -So Z1tif <br />N <br />SU rL�M <br />o00 <br />6,4SdLI.�f <br />K <br />6 <br />L <br />op c- '%'L <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name CSI \vim man `lam Date fJ— I I �y Iq <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 MANNERAS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SU9CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORWI ,,, <br />{ L/ <br />pplicant%Signature Title P1zOSdcr-,4--%69 L 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 />respons'bility for <br />jthe billing by signature and date below. q <br />NAME G3 K W _ TITLE S �.,�A� PHONE # 1 I b -Cl `f L -763-0 <br />ADDRESS `+1 �t�-Ld 1 1h �uu^I t QI M <br />SIGNATURE DATE_- f// <br />1 - J <br />EH230038 (revlsetl 10130/12) <br />