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ENVIRONMEPTAL HEALTH DEARTMENT <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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � <br /> Facility Name r t r 1 pirn Phone# 1-69, 949 , 24-18' <br /> Address LKS75' 9 S`���Taa I I S74 <br /> TCrass Street h 4C ac <br /> Y Owner/Operator SAf6-4*F&-V S/1W 4 H- Phone# VQ�j— $Y;(p—9/sig <br /> oContractor Name 1�4C aj,ef �(,Q, Phone <br /> N Contractor Address 5c,(O G �( U-. CA Lic# "KI I Lr7 I Class A <br /> T p jj+K`Ic 61 <br /> R Insurer Work Com # <br /> A <br /> C ICC Technician's Name �h (( (a 5?52#0L0 Expiration Date I—lel—IZ <br /> RT '" " ' �" <br /> ICC Installer's Name Lt(,LyytQ 5257�{l'xv Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> lie.sr piping sump,et le�dsl r,UDC tn, I Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A ment With Conditions) <br /> ADateN Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA TH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENPS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT ETAPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSA N LAWS C CALIFORN " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANC OF THE RK FOR CH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. 1, Q c p <br /> NAME SA-"066-P J�NL1� QgTITLE (4t�IO� L� PHONE# ` 04a� � 11!i <br /> ADDRESS 4 0 S� t, ) I )Jvc_L k)kl CA OS- 11-1C <br /> SIGNATURE DATE 09 <br /> EH230038(revised 0782/10) <br /> 2 <br />