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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 />d <br />TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # KQQ—ac3,iQ <br />A <br />O <br />Facility Name �q "eta <br />Phone # Q 7 0 -- a.q 5Z <br />I <br />Address M4 (Q w. tt4cl yt. �p <br />T <br />Cross Street C -a Mo,..( F(a Cloc�1 <br />Y <br />Owner/Operator �p Cc�t0.lJl- C(4a <br />. <br />Phone # Zoy- 530.-%.Q S6 <br />o <br />Contractor NameAbu- `t -l --e lzw <br />Phone # "-Z <br />T <br />Contractor Address ' -PSXUt*--CC54. CA Lic # "� (a„&l.(q Class sr At(r(Q <br />A <br />Insurer5,k30u'Cz-c-&- ` "`Ff4t_ e& <br />Work Comp # WfL Zoo I6030G <br />T <br />ICC Technician's Certification Number ja3c(-S (Z .. UT" <br />Expiration Date t' Q -q a -CQ <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />t. <br />P <br />❑Appro <br />d proved with conditions ❑Disapproved <br />L <br />A <br />RSAiftachmentith Conditions) <br />N <br />Plan Reviewers Name <br />/ <br />Date <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." '� (e' n tt'' tte- <br />" <br />I 6 a' / / <br />Applicants Signature itle ,e f��- Date 1 <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 <br />o_r-the billing <br />,by'signature <br />.and date below. <br />NAME If �t�0'--�� W�� aiILIJI TITLE <br />`S {Lyh(L((iyUAA[�C VQ'tr�-C`e✓ PHONE # <br />ADDRESS � l 6 4U 4k,& Aual <br />, <br />SIGNATURE �1 &.l..i:&tL-1 <br />EH230038 (revised 12/31/07) <br />1 <br />!17 <br />