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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 APPROVAL DDA . INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT LJUDC REPAIR/RETROFIT LJCOLD START/EVR UPGRADE <br />F <br />EPA Site # C, AL OW 3211 6b <br />Project Contact & Telephone # �„� �� t' 5o Qy� 888-02- <br />A <br />O <br />Facility NameCk � �$ 11 $� <br />Phone # ' ©l S Z -Z,Z 13 <br />< y A <br />Address O8S r�hti Pafkw JTpc C�:F� ��40, <br />T <br />Cross Street 8 Milt jZd , <br />Y <br />Owner/Operator �'��C �� �pX =InC , <br />Phone gq—) v) (o <br />c <br />o <br />Contractor Name 5",0� <br />aZ Se,�vice Md1in ahc�2 <br />Phone # `ll(� 31(- 23 a0 <br />T <br />Contractor Addressj�� j3o 933 W, 5ac�rrwiean�v nt'stO�l <br />CA Lic# y33j , 9 Class 7�0 <br />A <br />Insurer Ow t in 'XN5L1rC1q L SQ.N►t$ <br />Work Comp # "2-21 06Dd 1 800-) I <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />Zp o00 <br />LN'Aaf LA t�2sal��.t <br />'1 1 <br />0% <br />T <br />-\6 -k-j <br />A <br />N <br />2 �t <br />IZ1000 <br />Q1e�vtid+n Nl�c 5o,,l <br />K <br />23 <br />A Doe <br />D+ese l <br />-fit <br />o(� <br />P <br />[]Approved pproved with conditions []Disapproved <br />L <br />A <br />(See Attach ent With Conditions) <br />/— <br />j <br />N <br />Plan Reviewers Name /� Date 3 / -> <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. A/� / G <br />NAME ����yl 4fl�jpt^ TITLE l,�ON�pit aiAClt MaKAK PHONE# I U`il 888"bZ-1 (o <br />ADDR <br />TL- (,01-N <br />SIGNATURE <br />EH230038 (revised 12/31/07) <br />