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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 REPAIRIRETROFIT ❑COLD STARTlEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ritrt I C i.#A,e-L WA r i P4 X04 -3-�3- it S- <br /> �- <br /> Facility Name - I~V" '� 1�!i} Phone# 2 R _ �� 3 "I z s9 <br /> I L Address Z 2 1 Lt C L, <br /> ! Cross Street �(h V <br /> T _ <br /> Y Owner/Operator _ �, Jl�,# 4 Phone# <br /> C Contractor Name WA L,rOA 5 CS 1 nL 61t,rT.lrl(� c' Phone# 916 3 <br /> O <br /> N Contractor Address 8 oy( f a z v- u)• S '0 9 S$cl k CA Lie# 6 1Class A, .5, 9 A z <br /> T <br /> A Insurer rt A't'e- Fj wn Work Comp# <br /> TICG Technician's Certification Number S S.11- A-T-T'A-C# Expiration Date <br /> o ICC Installer's Certification Number �&_ ,�T 4-e4� Expiration Date <br /> R <br /> Tank Size Chemicals Stored Date UST Installed <br /> Tank LD# Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved pproved with conditions [ Disapproved <br /> L ee Attachment With ),Conditions) <br /> A WiZSbf� <br /> N Plan Reviewers Name <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 /> HOA�I IN THECOMPENSATION PERFORMANCLLOWING: "I CERTIFY <br /> E OFLA!V HOE WORK©R IA ICHOTH THIS IS ISSUED'S HIRING RI SHALL OEMPLOY IPERSONS SUBJECT TO WORKER'NG SIGNATURE CERTIFIES THE S CO PENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature <br /> Tide - Date t <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 t � TITLE� .A'VI`D`^ PHONE# <br /> ADDRESS O , U a }C f O T <Z A-t,,t-a C 4 r6 <br /> SIGNATURE 'r <br /> EH230038(revise 12131107) <br /> 1 <br />