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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 <br />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 <br />EPA Site #(A L 00r,.)'310 ( -60 <br />Project Contact & Telephone # --yC7'r11 - <br />A <br />O <br />Facility Name _ q' � e -Ur %, <br />��q c� <br />Phone a0 ! - g-jO - 34t <br />n <br />Address 574 if c es- �R!}/�"- j/t�� 1� 77zAG C'4-11-s-gX <br />T <br />Cross Street T4 Aet <br />Y <br />Owner/Operator RA m es tf. 6D D <br />Phone #1^161? —335 <br />Contractor Name 11 &L fA 13 L. C Pr`TRQt_6U /Yi <br />Phone #,-V& 7_ 945 <br />T <br />Contractor AddresaVI 3 .5 _ <br />CA Lic #� 6 Q Class <br />R <br />Insurer �' , t/�Lrf� �ATM � <br />Work Comp # 5 to %� f k/tf <br />TICC <br />T <br />Technician's Name R ,,,� ��i.— %3� N / <br />Expiration Date <br />RICC <br />Installer's Name 9-0 ilwf -R 7 <br />Expiration Date <br />Tank system work area <br />(i. e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />J Approved J Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />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 F 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 COMP SATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOR NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />`� ✓�/ <br />Applicant's Signature Title Date ff <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature `amend date below. j� / Q j <br />NAME RAM fit° t3V UyJ TITLE C/ 1 � ��Z � PHONE # �� �`p3� �� ( 6 <br />ADDRESS t7 / �.t:�� I ! e- eltrr 1 -y I _ T - ct cA - /s 3;Y <br />SIGNA <br />EH230038 (revised 07/22/10)��tw^ <br />2 <br />