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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 />STANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # C s\L- ('CU o- ,; 1(0/C ? <br />Project Contact & Telephone # J,0'7 — X 33 L � <br />A <br />C <br />Facility Name A r- C 7/VE <br />6 <br />Address6--74-°� &�� 42- AA ? e/44--7 � C - Gr 1 S <br />TCross <br />Street '-T f e <br />Y <br />Owner/Operator M Ls 6Z) 0 <br />Phone # <br />o <br />Contractor Name Re ---L A (S L � � & v LV Ulyj <br />Phone <br />N <br />T <br />Contractor Address � <br />CA Lic# (j Class <br />�� C <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number 5 Z� Z S,4 -- (j <br />[ <br />Expiration Date 6 <br />p o b <br />RICC <br />Installer's Certification Number S �Z��Q --�,e r <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />uAppro N4proved with conditions ❑Disapproved <br />L <br />A <br />N <br />(See Attachment With Conditions) <br />U <br />Plan Reviewers Namely <br />Date <br />U <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 !N <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 PERFORM NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title Date �b <br />-i14A1►UMIIII L3,91VPIIG\ILei ►l1 <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 I� ` <br />A I �C 'b TITLE_ %( JZ- PHONE # <br />ADDRESS -1� w'f <br />SIGNATU <br />EH230038 (revised 12/31/07) <br />01 <br />