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M <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQM 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 GATE INDICATE PERMIT TYPE BELOW. <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT PkPOLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# V�/PR IFFPYY 925 <br /> C Facility Name Thor �e vron o s f R maces Pn«,e# 2SCITF 72 <br /> I Address IiO S-T % N. N l v wa 1 <br /> L <br /> TT Cross Street <br /> Ovmer/Operator �(`n��4 i Phone# ZS 1972-1? <br /> c Contractor Name .v/ : �G /^ �` ( �c�✓r^ . Phone# <br /> N contractor-Address ;?/g/ &4 ' STS A CALlc# Class <br /> TWork Comp# GSI z '317 -2001 <br /> R Insurer j- <br /> c ICC Technician's Name � « �? V � � Expiretion Date 1(d <br /> T <br /> R ICC Installer's Name L.ATz(,4h-x -2- L'/J / «�4'� PI On Date i� i o /o <br /> Data UST <br /> Tank system work area <br /> Tank Size Chemicals Stared Currently Installed <br /> 087 POV WIM.91m tlebe"..110012,9i ) <br /> US ✓' ('d D UHIf}ta <br /> T <br /> ODD le tl <br /> Nh y <br /> K IVS VS`f— O® O <br /> UV^ U <br /> P ❑ Approved �gyApproved with conditions El Disapproved <br /> L ( /htachment With Conditions) <br /> A GJsys <br /> N Plan Reviewers N _ - Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN 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' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY <br /> THAT IN THE OR"E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CAUFDRNIA." 1 o 2 <br /> appliwM's Sign WmZz; Tt /'e" / <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 then the permit applicant, e.g. property owner. the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Fre- BWe-QUoc TI LES �° "•w,IfSY "`7J PHONES /Z `J �n�N <br /> ADDRESS <br /> pao Gv»� a� un ,,ll� ca 5 �So6 <br /> 1 r/ <br /> SIGNATURE DATE �t l�1 a� <br /> SJM38(revised 02120/09) <br />