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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 DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# µq w eL -408-ai.14c <br /> A <br /> O Facility Name Pev--skf- -,yukk— Phone# _qy.p.. 5'00 <br /> IAddress 3 �et�rr5�(il Ind) -3 InA gSotf— <br /> T Cross Street e-F <br /> Y Owner/Operator IAJ� 0 Phone#as q ci p_ 00 <br /> C Contractor Name �'eV�f c��Q, S "E[CN �' S Zkc, Phone# 4e)Y — 13,6689 <br /> 0 <br /> T Contractor Address ( V ��, SS �R 4SE CA Lic#4 r'� $C( Class 641 )b(i <br /> A Insurer sS j � �e,�, Work Comp# 33 O (%;3 (Da I <br /> T ICC Technician's Certification Number O '�D 7 Q — UT Expiration Date <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ��I/ y�,�¢ <br /> Applicants Signature i l' L. V• 4itle Qld.C"� V Il (tkt Date it t a-tJVV <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility fora the billing by <br /> signature and date below. � ��� <br /> NAME q�V`V" W(.l" Z1LIA�C�V TITLE (b!AQLl('LILA 64-11L�'�fY PHONE# A46 6 �2Q3C) <br /> ADDRESS �V lal V 4Nl Ul '� U (ill <br /> SIGNATURE l�6� l3[.I.�tM/ V• `�E-� FTS L�L$�LU <br /> EH230038(revised 12/31/07) <br /> 1 <br />