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MAY 11 2009 <br />ENVIRONMENTAL HEALTH DEPAd ,T,MB LTH <br />SAN JOAQUIN COUNTY PE8m1TIsE VI ES <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 A� PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # µp- (),Jetii{,Lik <br />� <br />Facility Name S eke 4 Phone # ;Z0q _ q"7Z -51406 <br />Address 4 L�a,5 N, cte�-iiG Stpck.�-oan CA Kab7 <br />T <br />Cross Street ctvvjfv-� Sk-- <br />Y <br />Owner/Operator CIO-J"O ✓ <br />Phone # Q00(- t47 a, - � bM <br />o <br />Contractor Name ArI-jl,e t"(QL.(.1A' 2cA.C:I(1�� -��, " <br />Phone # 40`1-i34% _ k,3 <br />T <br />Contractor Address 3 a,' [LsV.0d TVW CA Lic # S/�$ Class —4(a- CtOl ddl <br />R <br />A <br />Insurer SusU'�QLLCL ,t' <br />Work Comp #W�LSODo4o03C0 <br />TICC <br />Technician's Name <br />Expiration Date <br />QInstallers <br />R <br />ICC ' Name {, ( a�M4� <br />Expiration Date 113,1 ly I �)Ztb <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved /fl Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attac nt With Conditions) <br />N <br />Plan Reviewers Name Date ���/U� <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 <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.' <br />//��/ <br />Applicants Signature La.381e & Date Ut—a l aco 7(� <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 �siggnature and date below. /� t. . '. � (y p <br />NAME I-�aL�p (� �' w"e-LA d1-Gt TITLE QQR&i40F��u VQ'tt�;:'v PHONE# 40p`w3- �0� 0 <br />ADDRESS b 0 V QUOVIfA Amt,. S(�I.l -AOSe 0A l t'+ � a+ <br />SIGNATURE 'hi Oi leu A. k i . I V..0.4AA.0 & ,f.0 nATF \r/@ h -W Y <br />EH230038 <br />OF <br />