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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: (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 />❑ TANK RETROFIT XPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # OP7 7 l? <br />Project Contact & Telephone # , �V.AWC PA1C('40,- '7I6 << C�►C• <br />A <br />c <br />Facility Name C hc�; �,�,u 15 t gas <br />Phone # <br />I <br />L <br />Address lQuSv `Trim �Avk ve -ivcl�iflheA <br />TCross <br />Street <br />Y <br />Owner/Operator ll�Ev���.� ��,�13 <br />Phone# q 8q42 180 <br />C <br />Contractor Name ,,�;� Qe r r L <br />Phone # <br />T <br />Contractor Address �.� �Mct t� � n�� F 5 <br />CA Lic #'Z00 Class B C 7/N Aj <br />RInsurer <br />A <br />Work Com # <br />p <br />T <br />ICC Technician's Name 5 •3A <br />Nuk. ttvve <br />Expiration Date 1b5 <br />° <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />Q late YC <br />A <br />N <br />e L ✓` <br />K <br />PI( fay rlly 0 - <br />ll •: ��'. to e <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />e At achment With Conditions) <br />A <br />N <br />/ <br />/ <br />Plan Reviewers Nam v Date <br />APPLICANT MUST PERFORM ALL 440RK 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." CONTRACTOR'S HIRING OR SUBCONTRACTING 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 CALIFORNIA." ff 2 <br />Applicant's Signature m !/ Title ��TT✓�� 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 />responsibility for the billing by signature and date below. c7 / <br />NAME S �'1 / /�?Uir� 0 0I� TITLE _5�y PHONE# ��� U `✓�� (� `r5 <br />0 14�e )u;le <br />SIGNA <br />EH230038 (revised O�P7�/11) <br />2 <br />5 <br />