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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 />� <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />{ <br />❑ TANK RETROFIT N PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # F4 <br />� <br />Facility Name S &{.dQ 4 Phone # ;20,? —,417.1 .-8 L 06 <br />� <br />Address 6�'As N. 4ei-ke, StDtk�'o� CA quo I <br />TCross <br />Street Kh.*I, j S{-, <br />Y <br />Owner/Operator E:j D_ V- <br />Phone # <br />D <br />0 <br />Contractor Name ,Ar}�te >).{� �Q a,e �, <br />Phone# 461t <br />T <br />Co n I ra cto r A d d res a 3a,-L� CL-, CALic#3fag 414 Class'(A-Cc (14 <br />R <br />Insurer Sys sV L �{— <br />Work Comp # w (�LS66 NDO 0 <br />TICC <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date lyI 19 I Q Oto <br />Tank system work area <br />(i.e. B] piping sump, 91 leak delecldr, UDC la, etc.) <br />Tank Size <br />Chemicals Stored Currentl y <br />Date UST <br />Installed <br />T <br />— <br />A <br />N <br />K <br />oil <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />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 <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 />Applicenrs Sig nature 8e Date_LiQ( gano 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 1siggnature} and date below. /� � ry <br />NAME I_`a tAti-�' W�-�A1L1.LQ.N TITLE 19411rb / � Vpt1'�(—V PHONE# qby-at3- (don <br />ADDRESS 1636 QUIM.IA JkU-C. Stell AOS�, eA -1 �l j �+ <br />EH230038 <br />038 <br />