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• • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQ IN 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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name Will AR-to All I Phone# 48. 243 <br /> I <br /> L Address G/ SS S• ;ll 11 97 T Aino cLhbh Cf} <br /> TCross Street <br /> Y Owner/Operator S /IV Ch Phone# Qt)Q-goS - 9(4 8 <br /> G Contractor NameQ UN„ 027vA• 4,. Phone# 20q.8k;S - 9fff-S <br /> O �I <br /> T Contractor Address 21 ry hIXl 1Za„ �-• 1I�q,�� t* CALic# $ g 3 Q(; Class f} <br /> R Insurer [' 1.n n M u.,kj� �GC.a,(o_ (.Qr Work Comp#�13- SOCIJk-Zo o <br /> C ICC Technician's Name L UP6 S'h4W4f Expiration Date 4 0 •-2011 <br /> R ICC Installer's Name IW6 QA'Ae O-f o'er Expiration Date 1 -15- - 201 1 <br /> Tank system work areaTank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detedor,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A 'r <br /> N Plan Reviewers Nam�P� _Date 6140 _ --_— <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 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 COMPENS TION LAWS OF CAL RNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN E OF THE WORK F WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature__ ___ __Title_✓�__"'— ----Date d/ _Q r Z d/ -- <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 /> responsibilit(y1 for the billing <br /> by signature and date below. �p Q <br /> NAME—_ S� • Sc_ f, TITLE S•�d ---_PHONE# <br /> ADDRES1D'o-hig&-- —/W_ h^�Clot <br /> l <br /> SIGNATURE— ___---DATE— <br /> RE <br /> �,0------ <br /> EH230038(revised 02/20/09) <br /> 1 <br />