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ENVIRONWtNTAL HEALTH DpeARTMENT <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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT IKUDC REPAIR/RETROFIT []COLD START/EVR UPGRADE <br />F <br />EPA Site # C &L (9 O 3a j <br />g <br />Project Contact & Telephone # <br />C <br />Facility NameF- <br />F 4 -7 $ q <br />Phone # j.09_9 5 )L - as <br />� <br />Address c)$ 2 F <br />, C <br />C a <br />T <br />Cross Street <br />Y <br />Owner/Operator � k ', N <br />1 —� 6, <br />Phone # - 8- o � b <br />o <br />Contractor Name B,�(Z <br />5i iDN �.CF <br />Phone # Me . 71_ 2-a 80 <br />T <br />Contractor Address 3p fibtx�e iv <br />. <br />CA Lic # <br />3 i Class d yp Cb <br />A <br />Insurer (' <br />c <br />Work Comp # 2_Z1pcnd Qj ) <br />T <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />Q <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />TE <br />A <br />O <br />N <br />K <br />�t� <br />%'0��00 <br />MESE <br />c O <br />P <br />❑Approved <br />AA proved with conditions <br />❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />-24& /m <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 />THAT IN THE PERFORMANCE OF THE WORK FC2 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />i <br />Annlinnnts Sinnature ' G t /�TJ� Tile/L� /NT�/!J ILIMA19L Dat //� O <br />BILLIK-GINFORMATION: <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. / G() <br />NAME�1V�,lC� FI �L(i%�S TITLE ���Pd�lu70)5MIV9itPHONE # �/3)`^�34` <br />�� �� /tet/� 5/ �,4 n� 4 9S <br />c .v �C� <br />ADDRESS 3O /7LJLC S�L� IlJ � <br />SIGNATURE <br />EH230038 (revised 12/31/07) <br />