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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 /> TANK RETROFIT i—iPIPING REPAIR/RETROFIT L--,UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# W2t"Fcu &Lt L(01-a-C3-463 <br /> A <br /> C Facility Name O,-+e 1J Phone# Z�LQ4 13 <br /> � Address 9fS4 W. L( 1+" <br /> I. - Cross Streeti. <br /> T <br /> Lc rvz�.. t�'m,flow . <br /> Y Owner/Operator S '� C , C IN-L&- e Phone# <br /> C Contractor Name Sew �. � S ���" Phone# 46 V_PL L3-- 41,038 <br /> 0 <br /> T Contractor Address 6% � �uK Auer S1 CA qSt(� CA Lic# lig s( 8LF Class'D, Cf�l -Z <br /> A Insurer uv -�f eo" work Comp# :33 i 60 a.QO'3 6 t <br /> T ICC Technician's Certification Number 53 If S'3 It — U T" Expiration Date s—j 3(( ato Si <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 ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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." Q xp <br /> r e 0' U <br /> Applicants Signature itle Q(�-�"g ���-'ef 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 <br /> for the billing by signature and date below. �� p J <br /> NAME MMW V• WF-tT" AKI TITLE `0"k(0L41 a lJ'T(�tt`�CY PHONE <br /> ADDRESS V K)ZLILLL AUk, Sr�� �f•� CA 't J-��I a► <br /> SIGNATURE ,L V, " �V•'e-l% <br /> EH230038(revised 12/31/07) <br /> 1 <br />