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ENVIRONMENTAL HEALTH DEPARTS <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Califomia 95205 AUG 13 2014 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 �_NVIRON ME- <br />NTAL APPLICATION FOR UNDERGROUND STORAGE TANK <br />DEPARTMENT <br />ALTH <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERN.IT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />N TANK RETROFIT ❑ PIPING REPAIRIRETROFIT O UDC REPAIRIRETROFIT C COLD STARTIEVR UPGRADE <br />F <br />ITHE PERFORMANCE OF ;fie WOKK rcac wmiCn 1Ina PERMIT IS ISSUE), 1 JHAH -1 E,.,PLUT A � � <br />EPA Site # <br />Project Contact & Telephone # r�u � - (D D it _q 3 <br />C <br />Facility Name -T>r(A'% Le <br />03 <br />Address d �{ LL}. <br />G►Yti 2 `1 -y -a cA a S 3-7 (.v <br />TCross <br />Street <br />Y <br />Owner/Operator & 0_ <br />Phone #do9- 9'dL-3 <br />C <br />0 <br />Contractor Name FeAvIb\ <br />Phone <br />N <br />Contractor Address %j 9 3t7 <br />yr U � CA Lic # 8& --; 7 6 V Class <br />Ainsurer <br />Work Comp #t'`�� - <br />0ICCTechnician'sName <br />7 <br />s c�re-Z Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Dale <br />Tank system work area <br />Temank Size Chemicals Stored Currently Date UST <br />Installed <br />(i.e. a>,:plug s• s1 leak de,ecror, UDc 11Z �.( <br />y I 91 �-;Uri <br />T <br />,WD��� <br />A <br />N <br />K <br />P <br />Approved <br />roved with conditions ❑Disapproved <br />Ett <br />L <br />A <br />(SmentWith Conditions) <br />N <br />Pian Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIT -i SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />.OAQUIN COUNTY, ENVIRONMENTAL HEALTH CEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />- - 1-1 SUCH a MANNER ec TO BECOME SUBJECT TO <br />MANNER <br />.. -�_ ...- __-_-_ . • _ <br />WORKER'S COMPENSATION LAWS CF 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 WCRKER'S COMPENSATION LAWS <br />OF CALIFORNIA." .f <br />IApplirar8'sSignature <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 <br />billingbysignature and date below. p u p p I , <br />NAME QP�Ictbl� d' Vlr' J/t1 S�iV- �}.11 C - TITLE CLIn .LCJr7J t- PHONE# �q - r�- J b r(� <br />ADDRESS <br />SIGNATURE '�. x.r+E �'x*.10 y •r r CATE <br />EH230038 (revised 07-17.2014) <br />2 <br />ti'd £9699VO60Z uJneloJjed elQeile�j IaLti:90 ti 6 £ I. 6nV <br />