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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 DALE. INDICATE PERMIT TYPE BELOW: <br /> XTANK RETROFIT LiPIPING REPAIR/RETROFIT —,UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# (���{(� � i.(d�-@LQ-40,3 <br /> A <br /> 0 Facility Name 4�eW Phone# aOl $3 6--2q 9-6 <br /> � Address S4. W.- K - <br /> I. . Cross Street Qt <br /> T. <br /> Y Owner/Operator SOC6W (A- 0 ,Q Phone# <br /> cContractor Name Se"�� {�-( N S Wes �"��" Phone# 46$_aL _ (Q43 g <br /> 0 <br /> T Contractor Address 11.%0 b `uK Aulp- si CA �{'j[lam CA Lic# /�� g4 Class�� C(�((gyp Z <br /> A Insurer �S�SvAL)V- --f. e0. Work Comp# 33 I QQ a,6'3 6a j <br /> T ICC Technician's Certification Number S3 I[S3 l - U T Expiration Date !rj 3(� JO(5^Y <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name _1 l/�`�j�j 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." ^ itle p <br /> agoApplicants Signatures L � <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 RIARTLW \11 W6V1"k14J TITLE C°o"l&��d-rPHONE# <br /> ADDRESS IQ V CU4"k 1��� Sck..� VOSC r CA 6#&W1 a► <br /> SIGNATURE �CbI-til- .L V ' j'V <br /> EH230038(revised 12/31/07) <br /> 1 <br />