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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 REPAIRIRETROFIT Z COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# NR S Nl+,6 PATE L <br /> A <br /> O Facility Name 76 GAS STA Tr p� Phone# 02 g 3 S – 7 77.7 <br /> Address 2 5 7 g S p�T(��s N (� s kD T C 4 9_937 6 <br /> 1 Cross Street 5 8 0 ,FRE 12 W A y P ,p N S �' <br /> T <br /> Y Owner/Operator P re L g Phone# 299– +2 9 <br /> 0c Contractor Name kC1-14j3Lr. 00P T LEO M - C N Phone# 20� _ IS+5- S E 6 <br /> T Contractor Address �2 (�( CSG Y2o ni CA Lie# g g -7 U G Class <br /> R <br /> A Insurer B C Cnl v 120 NMN i_ Work Comp# N f� <br /> T ICC Technician's Name 5 Z S �0 _ U T Expiration Dat L}1.20 4 0 <br /> o ICC Installer's Name 52-so 5( _ U Expiration Date TA C1 IS ZO {1 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 1/2,etc.) Installed <br /> T N A <br /> A <br /> N <br /> K <br /> P ❑ Appro ed Approved with conditions Ll Disapproved <br /> L Se Attachment Conditions) <br /> A e 6�N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA UIN 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 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" RA / C Q <br /> Applicant's Signature Title C E (k I Date <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 9 fa rt t) F('(-STC L— TITLE C C_O PHON-E'# 5110 - 4-6 9 - 9 543 <br /> ADDRESS Z 5� 7 S S V ft ( (Q_ f D{ �. i ` CY{ ` A `f ,7�b <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />