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ENVIRONMENTAL HEALTH DEPART I EIVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 MAR 18 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK l;�A'Tl�r FD9DTAl��T <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 XUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# f- 5/* 9/,k-jyb-9e,go <br /> A <br /> C Facility Name G O STGD d e sy Phone# <br /> I ress L G <br /> L Add3 6 4i kst�T LrNf RD. ?P-A&Y <br /> T Cross Street gY", (iQ- <br /> Y Owner/Operator GOSTGp Phone# 7e9- 93y- 12y7 <br /> o Contractor Name WA y^�if Pf/L Ry Phone# 9/�[' - 6LI6- 9 ,91 O <br /> N Contractor Address ♦ + r PIA <br /> T 36 ,niA,-1 U1 -'51-t .S e.rn/+-rn CA Lic#cA 3r-o3 yS Class�.� s+ 3v J761 <br /> R Ir SUrer <br /> A +LQ S'ro. ,g 64 SY MArsbinL'r vXu5.A&9wcY- 511 AlTfAcHEO Work Comp# e3 Ll VL/ 7 L7 72 7 <br /> T ICC Technician's Name ,V/ S <br /> L 0 4/LVO-Y Expiration Date Z-Z6-(7 <br /> QC Installer's Name <br /> R ICI ' Nre-NOW'S fjarvL y Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i,e.87 piping sump.91 leak IaWOcr.UDC 112.sIC.) y Installed <br /> T UDC VZ 6AS6 Lt. E <br /> N UDG -57& 6&S6 1_1^1t <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( Attachment With Conditions) <br /> A U IN- I � <br /> N m <br /> Plan Reviewers Nae Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUICO TY 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title PM1C$Ite`f ~-46L/`- Date 3— ) 7- / S' <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 and date below. <br /> NAME(,147A4 r�4'r�'�-'/ TITLE PAOT&r A'rA.+4604' PHONE# 9/6 -(�IV6-9690 <br /> ADDRESS 3(7 /L/flw Ave -6-ri lS !!5,94/L4,-"Aw TO Cry. 95838 7 <br /> SIGNATURE DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />