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03/22/2012 06:17 0000000000 OLLLEt*FttItItItIttON PAGE 02130 <br />ENVIRONMENTAL HEALTHH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax:l (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 />0 TANK RETROFIT XPIPING REPAIR/RETROFIT ❑ UCO REPAIR/RETROFIT n COL❑ STA PTfr vv I ior±o A r. <br />A <br />AF <br />EPA Site # Project Contact & Tel phone <br />C <br />, , <br />Facility Name,/Q1 ��.�G �rpf'eu ,Vi [tom APhone �� 7 <br />37 Z. <br />L <br />Address ITT rCs5ltn vG . <br />Cross Street�,� <br />Gwner/Operator /e� Phone # 84o w 4 �. � 379 Z <br />C <br />N <br />Contractor Name K�,,,t u✓rf ' �oMs/r c -/,uv, Phone �,��r�3�r'�%O <br />T <br />R <br />Contractor Address U oh 6'() 476 CA Lic # Class 9 Nig <br />A <br />C <br />Insurer �" „ j r5�1 1�� c r, e� r,� Work Comp # --- <br />- tri- cxa�rJ-� <br />T <br />ICC Technician's Name joz;ll Expiration Date <br />R <br />ICC Installer's Name L,� 5,,15 Explration Date <br />Tank system work area Tank Size hemicals Stored CurrentlCyData UST <br />(i.e. B7 piping aump, 01 look deteelor, U0C 11Z etc.I <br />Installed <br />T <br />IF <br />Laz <br />P <br />❑ Approved Approved with conditions <br />❑ Disapproved <br />L <br />A <br />(S achment With Conditions) <br />N <br />_ <br />Plan Reviewers Name <br />bate <br />APPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS S <br />CES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />GNATURE CERTIFIES "I <br />THF. PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY A <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRA <br />THC FOLLOWING: CERTIFY THAT IN <br />qY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />TING SIGNATURE CERTIFIES <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY <br />THE FOLLOWING: "I CERTIFY <br />PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Ap licanfa CO-^/ '.�--"4 <br />Signs re Tlile ►K <br />DNte 3 / <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended <br />beyond permit payment coverage per tank, if <br />the party designated below is different than the permit applicant, e.g, property <br />owner, the party must acknowledge this <br />responsibility forthe bilking by signature and date below. <br />NAME �Cr I S OePe4(jeL1V1 TITLE <br />PHf1NFtt 7_oll 5'R O 3 <br />ADDRESS I G <br />SIGNATU� <br />EH230038 (revised 08/1111) <br />C <br />2 <br />5-s 20& <br />TE ,/ Z <br />