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i <br />ENyRo�w <br />J,�ETAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />FEB 2 6 'East Main Street, Stockton, California 95202 <br />T ne: (209) 468-3420 Fax: (209) 468-3433FOUP-41 <br />�j <br />ENUIR0(vN4EPo <br />fl ,€_" <br />APPLICATION78'6%Oj' bROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />T <br />O <br />N <br />T <br />R <br />A <br />c <br />T <br />O <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT 1JPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />EPA Site # C A t— 0p cs Project Contact & Telephone # 0� <br />Facility Name . �Af� rZA S 2 <br />Address <br />Cross Street :Tff e <br />Owner/Operator � <br />Contractor Name l L A <br />Contractor Address5i NbX <br />Insurer C- Lam, /V k j (n <br />ICC Technician's Certification Numbers Z <br />ICC Installer's Certification Number Is- Z <br />Plan Reviewers <br />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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFS COMPENSATION ORMANCE 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 />THAT NT HE PERFORINCE OLAWS <br />HE WORK FOR OF IWHICHOTHI PERMIT IS ISSUED, I SHALLHIRING OROEMPLOY IPERSO S SUBJECT TO WORKER SSIGNATURE CERTIFIES THEOCOMP COMP"I CERTIFY <br />ENSATION LAWS <br />OF CALIFORNIA." N1 <br />Tank ID # <br />DApproved <br />Phone # P9— 9�-- 94 6 <br />Pm -T c y <f4�15S 74 <br />Phone # 6 — <br />L (ter Phone # <br />—=- <br />CA Lic # 9'7 j Class <br />Work Comp # <br />2 FL Expiration Date <br />Expiration Date <br />d r <br />Tank Size Chemicals Stored <br />Currently/Previously Date UST Installed <br />[]Approved with conditions ❑Disapproved <br />(See Attachment With Conditions) <br />Jae / Date =-- <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-PA <br />rn { TITLE �� PHONE # �� 3 <br />ADDRESS <br />2 4, 2 <br />SIGNATURE! CiEl <br />EH230038 (revised 12/31/07)^ <br />1 <br />