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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 4COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> AFacility Name APCH AtM Ak-Yw Phone# 209-909- 24 3 <br /> C <br /> � Address GESS S, 99 S'/btk-710AI CA - S,2-1 <br /> I Cross Street /-Qe1-t (LO <br /> T Phone# 2_ai ^4 a I -3-44,5' <br /> Y Owner/Operator �' yr,-p, � //.)V�TTw/g1-f TS, LLL <br /> C <br /> Contractor Name QEL) A$L6 P6 7A6 SERV/CFI, INC Phone# 9159 -$45'^ 8S'8b <br /> N Contractor Address 5 21 8jQ M1t)1A/ / DAD 9. M! W,(A CA Lic# $$ s 3 O(6 Class /f <br /> T <br /> R <br /> usurer r^, FSI Vl k ONI4EAIT hL b '17/FLLr C Work Comp# <br /> C ICC Technician's Certification Number 5252S- 4 O - U I Expiration Date Oq- 2�-20I O <br /> T <br /> G ICC Installer's Certification Number SLS 2 S-4 O Lj Expiration Date 64- /6-2-13/0 <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T P4 <br /> A <br /> N <br /> K <br /> P []Approved Approved with conditions ❑Disapproved <br /> L (See <br /> mAttachment With Conditions) <br /> N Plan Reviewers Nam� f / �-�s- —Date- l--_---_— <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 /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PE RFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Title ___— Dale_ , —� <br /> ApplicanLs Signaturek4t — --- --- -- -- <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 an^d date below. <br /> NAME_ LS//��I LI _ T,IITTLE__OW&� g2 _-__PHONEn <br /> ADDRESS�US s • h� l�A- '7 / / OCJC TO/-4 _C A �'!S2 15- <br /> - _--__ <br /> SIGNATURE_--_ � -- <br /> EH230038(revised 12/31/07) <br /> 1 <br />