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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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVZUDC <br />. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT EPAIR/RETROFIT UCOLD START/EVR UPGRADE <br />A F EPA Site # C AL O00 3 L j Eb Project Contact &Telephone # Er t 5otz yl �8i3 pZl <br />G Facility Name Ck # a� Phone # l 95-Z --L-L 13 <br />� <br />Address Ogy `tn,� Qarkw 54oc CA 9� `i <br />T Cross Street milt IZA <br />Y Owner/Operator ��C� I� -V-�OX Phone # ayl <br />o Contractor Name aZ 'be-lwie c 5k!A\L)"� MA' c)hC� Phone # ��L <br />N Contractor Address �(0,ki <br />T T, 0 �o CA Lic # y3315 Class j3 yp <br />R Work Com ' 2 <br />A Insurer Q ttn -� w1 YVAS L'(c?11C.t SQ.vit 5 P # Z I DOD01 8001 <br />C <br />T ICC Technician's Certification Number Expiration Date <br />Q <br />R ICC Installer's Certification Number Expiration Date <br />Tank ID # Tank Size Chemicals Stored Date UST Installed <br />Currently/Previously <br />T ( 20 cco i�i�uld( l,in�rc�•c� �sat�`•c �I t c(o <br />A 2A 1 ' <br />IN tZlo°o Wewt,Ja, C& <br />K 3 8. pCe D e sell <br />P ❑Approved ❑Approved with conditions [-]Disapproved <br />L (See Attachment With Conditions) <br />A <br />N Plan Reviewers Name Date <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: "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: "1 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." <br />Applicants Signature Title 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. <br />NAME Eff 1A5o TITLE �t►1[)It ai1C3 /' Idptc��l(� PHONE 4-1 �LI> 6tS� �iZ 1 io <br />i11' p I 7— <br />ADDRESS�`{ ftp "y,()10 �{ I�ft TL (o0 ( -L <br />SIGNATURE_ <br />EH230038 (revised 12/31/07) <br />1 <br />