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0 <br />0 <br />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 186 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility NameZr f!, F� r9 ca , <br />(/ %. Gy cq <br />Phone # <br />L <br />Address /.r_/ o i <br />I <br />T <br />Cross Street c" <br />Y <br />Owner/Operator Z /0 <br />Phone # -7lel 3.3 1 <br />,, , <br />4621 <br />C <br />Contractor Nameri�� fJ y� <br />Phone # <br />NContractor <br />Address , ter, �� ,`, � � � ,fy, , f�� <br />CA Lic # � 0/, - -2,� class A)36 42 <br />R <br />A <br />Insurer <br />4' L� �i? <br />rfr, <br />Work Comp# 00 e-1417 2- 70 Z-7 <br />C <br />ICC Technician's Name ti <br />" <br />Expiration Date <br />oR <br />ICC Installers Name, 2,,:, <br />Expiration Date,5 �7 `S�ZJfZ�W <br />Tank system work area <br />{i.e, 87 piping sump, 91 leak detector, t1DC 112, etc.) <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />� � � - �ii1A . r <br />Z25 'A- / � ` .� <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />inn <br />Plan Reviewers Name 1I• r ' IV�`l a -t- Date -7 <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 EMPLOYANY 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title ,,Q-4129 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 k-7 G �`�r r' a`1 HG TITLE / �"7 G /QY" PHONE # <br />ADDRESS G' tit/rte ✓5 e--,.%� <br />SIGNATURE DATE <br />EH230038 (revised <br />2 <br />I:A <br />5' <br />