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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />STANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # CAL 00012-118,; <br />Project Contact& Telephone # ' IU, Er;e*so," (847 SPil-OZ7(o <br />A <br />D <br />Facility Name(itAiQX 'AM4 *-)'781 I Phone # : 095 L - L Z 13 <br />Address 081- j �,y�;j Pyr ICwd <br />T <br />Cross Street a M�It 2d. <br />Y <br />Owner/Operator T14`1L t� y�e �: L c <br />Phone # ( EAq-i $&;) '02-74 <br />C <br />Contractor Name 9 N►C - &J 11 JZSo M A4 Al AJ -t- CO <br />Phone # 209 7- 75-73 <br />" <br />Contractor Address Pof3oX 313Z5" 5'rk^' CA ?5-Zc3 CALic# �,s(� j1 Class -2-1 +�%O <br />A <br />Insurer -T-47F, f7-v"A N .k Comp # IV05_6 O <br />C <br />T <br />ICC Technician's Certification Number .S 30 O 1,P1 - UT <br />Expiration Date I Z I/$'108 <br />QICC <br />R <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 />T <br />-I c uta ✓ <br />20 <br />Q2 v a r i 1. <br />7 ZOc; (� <br />A <br />N <br />Z_ �i �w�wnn <br />�2 K <br />ft►vl;�m <br />K <br />3 ' �, es -e -I <br />BIC IUL <br />S7 Vt{S� <br />i ZJi.CN <br />I <br />P <br />❑Approved pproved with conditions ❑Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />/ <br />Plan Reviewers Name Date (� 2 <br />APPLICANT MUST PERFORM ALL VV5RK 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." <br />_ / <br />Applicants Signaturk,�.�.( � Title �NFZ/T`C /j Date //-2-1-07 <br />BILLING INFORMATION; <br />Indicate the responsible party to be billed for additional EHD staff time expended bevond 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 1>4�o A Eficiefio^ TITLE C-,0P1IP4C.t I4411.'IaUt-PHONE#_ 471 S�C�'C?7.%�✓ <br />ADDRESS <br />SIGNATURE 1 c X A <br />EH230038 (revised 8/3/07) <br />