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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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#ham '��• �� <br /> � Facility Name VAMO 1&&0qq3 Phone#12CQ I 072 r g$trj <br /> � Address Is, 15• iiTrk sivmnr ac" , <br /> Cross Street S <br /> T <br /> Y Owner/0peratorvRZ(2)) L 0b. Phone#SSq . 3/ 8 <br /> 0D Contractor Name & k� S S6a%ACM "C . Phone#-qe% . o t <br /> T Contractor Address •C), 0%)LC"-4C&qStao I CALic#-jL47 i Class #!I, <br /> R Insure 1!J! �L Work Comp <br /> A <br /> T ICC Technician's Name'r Zq-Z lt'( Expiration Date I.{ •'Z.1 / 'Zoll <br /> DICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> O.e.87 piping sump,91 leak detector,UDC 1/2,etc) Installed <br /> T -I 10,OM (Z 10 l <br /> N 3104 -2 to t�t]O �2 k) o t bl <br /> K (pq -3 to lQ <br /> P ❑ Appr ed Approved with conditions ❑ Disapproved <br /> L (SOXta <br /> chment With Conditions) <br /> A I II ! <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL W RK IN ACCORDANCE WITH SAN JOAOUIN 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE HEkWRI FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> ` [[���f I11 /0.71 '?GU9 <br /> Applicant's Signature Titlel' II�{/�7�f"t 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 <br /> for the billing by signature and date below. '],� �p <br /> NAMENf4U""- l.0 TITLEI�NITf-CE�.H PHONE#�'� r(D'�$� Ul� <br /> ADDRESS�• +•� F-�' V='11 "I`� --I <br /> SIGNATURE DATE ID '-n I L <br /> EH230038(revi d /20/09) <br /> 1 <br />