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Jun, 26. 2014 11:13AM <br />No, 4307 P. 1 <br />ENVIRONMENTAL HEALTH DEPARTMEICQ D <br />SAN JOAQUIN COUNTY E ED <br />1868 E. Hazelton Ave., Stockton, Galifomia 95205 REC <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />JUN 2 6 2014 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. DEPARTMENT <br />0 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT )(UDC REPAWRETROFIT ❑ COLD STARTIEVR UPGRAM <br />F <br />A <br />EPA Site # CAXo,0o Zoi iia 6 <br />Project Contact & Telephone # iB LAA),)ae, ;,M�rli y/� syy 17 <br />Facility Name G N Il am -36-7'769 <br />Phone # <br />Address 1,0856 v-1-1;ry cel, <br />I <br />T <br />Gross Street 9) 6,q -r /j 14 f2,oA p <br />Y <br />Owner/Operator C qfI j Np,) <br />Phone # 1% 2 / /a <br />o <br />Contractor Name <br />Phone # <br />T <br />Contractor Address .30 /1°16110 AVf jA,p jrj,,,; d --A. CA Lic # 2,00 3 y,5' ClasSA <br />A <br />Insurer 14 , Z ,��v�29N c 0.�+�► �A.� <br />Work Comp #C0 y 7 z z <br />C <br />T <br />ICC Technician's Name VA <br />,t7L+�U+4 64064A) I <br />Expiration Date a •-Z ^r,s'� <br />R <br />ICC Installer's Name pa,04 i.o Expiration Date 9 <br />Tank system work area Tank Size Chemicals Stored Current Date UST <br />(i.e. 87piping aump, 91 leads dekofor, WC 112, 9(c.) Installed <br />T <br />)Ff6uLWL <br />X7[1 000 <br />e_1A.s6 LI.vi <br />A <br />N <br />Sv Atm <br />ood <br />64LO LICE <br />K <br />aoo <br />t7/E54 L <br />vp c- <br />0Z- ply 004- <br />ufl� 1:5�/& UPC 0))71 <br />❑ Approved Approved with conditions ❑ Disapproved <br />P <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Flan Reviewers Name Date ib-2-6-IcLq <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 />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY <br />AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SI4ALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA," <br />Applicant's Signature TIC, j �d � � M�'��L �'� Dal. <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. It <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 />W <br /># -76156 <br />ADDRESS 5 <br />j0 <br />�01�A L r\ A`,� a,8 CIA I ai qs (0—/1 � r <br />SIGNATURE v ''' DATE (CI "/ 1f T <br />EH230038 (revised 10/30!12) <br />2 <br />