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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 STARTIEY"PGRADE <br /> F EPA Site# Project Contact&Telephone# 11U4 �)&1 ,A/l <br /> A <br /> C Facility Name K` Phone/# d _ _ 6036 <br /> Address 366 A fV n (-4 <br /> T Cross Street Poil <br /> Y Owner/Operator ;ry� S Phone# 0 7 - /,5'00 <br /> C Contractor Name 5 d 1$ ` Phone# <br /> N Contractor Address CA Lic# Class <br /> T 6 Su u�� fie, o I�C.bi 1�! <br /> AInsurer C ' , M Work Comp# 3 v6 <br /> TICC Technici n's Name <br /> T �j��,,,1, �Q�(oa � Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N ol <br /> K <br /> t <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 <br /> TO 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." ii'' r , ,- _ ,�( S ,cy� <br /> Applicant's Signature V V .LLL-G�ifie L",L C-Q, C` a.,t.v Date �S �' <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�'VNRT 'N 4" L-CE {�t I�a-' TITLE Lta-L' C-IlL 644VPHONE# 4&`- IkI63+�Q <br /> ADDRESS Auk, 50—.LL Vnse— (+A 9 <br /> SIGNATUREGI F 1.1.1,. "- "r L L1 ,L l.L� DATE 3 I 1 I f <br /> EH230038(revised 02/20/09) <br /> 1 <br />