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ENVIRONMENTAL HEALTH DEPARTIN"O iJ;`; `;10 <br /> SAN JOAQUIN COUNTY <br /> 600 East Alain Street, Stockton, California 95202 SEP <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIR';i'':'';:' a 1TH <br /> �3 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ppI� THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DALE. INDICATE PERMIT TYPE BELOW <br /> .pTANK RETROFIT ❑PIPING REPAIR/RETROFIT ,UDC REPAIRJRETROFIT JCOLD STARPEVR UPGRADE <br /> FA EPA Site# Project Contact&Telephone# µti <br /> C , Facility Name S&A-CLUCLU f Phone <br /> L Address (Lt{21V F�ali�,,'(� Alf S{oC1L}C1'1CA, S�0'1 <br /> T .. Cross Street <br /> y Owner/Operator (,e0. Phone# Q,'I,S..�``7.. Z q 6,7 <br /> NContractor Name •U, f[t.ht. A $ 5teW4.1Z .-Ca-.0 Phone# e fd$ _ (pa37 <br /> R Contractor Address (�g (� �L}Q ,usdaL CA Ulf CA Lic# �{ft-18'F Class C 41 Ia4y <br /> 0 <br /> A Insurer Y�eSS (uS b.✓Q .GLi! (°.� 2 Work Comp# 3'3I()OaY,Oa 0( (c <br /> T ICC Technician's Certification Number S' 3 U 7 E <br /> S — UT Expiration Date �l'IT n.o(59 <br /> R � <br /> ICC Installer's Certification Number <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored <br /> Currently/Previously Date UST Installed <br /> T <br /> A <br /> IN <br /> K <br /> P ❑Approved �pproved with conditions ❑Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date �Z O <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: 1 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." 1 1 <br /> Applicants Signature V' Y" hle baLuil Date 1llot, Wv <br /> BILLING IN ORMATION: <br /> Indicate the responsible party to be billed for additional EHD Staff time expended beyond permit payment coverage per lank. 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 <br /> 'by"signature and date below. //Gt� /��� �1 <br /> NAME K4LVkiIl&-T L04tkLN, &-1,I TITLE CDWA0[J&U(-e (Jt'tL(tV PHONE# q08-9434()V 0 <br /> ADDRESS 1p 0 Q,U LtA R oA111'e rCLk -(QT C X g S I 1 1_ <br /> SIGNATURE '�"w <br /> EH230038(revised 12/31/07) <br /> 1 <br />