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►] <br />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 DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT I�ICOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Wet4kitLai4 4R-g,(V 60-11 <br />A <br />O <br />Facility Name u(� Phone# a01 -47a,- $1060 <br />L <br />Address (�L� as N. �0.C1 Etl� /{ Q Slzc(c-tvo C/4 4540,1 <br />T <br />Cross Street C4ulEV0 *� , <br />Y <br />Owner/Operator CI ITLNO/ �v CEtbLA <br />Phone# 204- A{1.5-- %6D <br />o <br />Contractor Name Scuv��Stwtlo.' S' S+etk5 x." <br />Phone# 46Y-Ql3- (OC -Sr <br />T <br />Contractor Address (0�0 &06kjA /w -e, SJ eA af5((a,, <br />CA LID# cit 81.4 Class -6,Clei ID0 <br />A <br />Insurer C `k5S T�svvo-ue-t cle•6&mt&y <br />rk Comp# 33100a663(o68I <br />T <br />Technician's Certification Number a SE{ <br />ICC ThCiS SSS' — ur <br />Expiration Date 3(eL4' aDD <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved Approved with conditions ❑Disapproved <br />L <br />(See achment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date I Z X? <br />APPLICANT MUST PERFORM ALL WC5RK 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: "1 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." A� �1 ��Y� <br />Applicants Signature � VIa-C.: 4i , - �IV..Q.(�L.L/.LitLlUtle t-CJliipUQ.Lt�L1i'tLC�y Date I a'1 I / a" <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 �Jy for the billing by signature and date below. (y '- � <br />NAME" �4A1' V"" ��LY-I.tlLe4it TITLE �-O N,I�LO;( �iT-I { PHONE# <br />ADDRESS 6D Uo,-LtA k2. So -Lk- -Icy- CBL Vit <br />SIGNATURE arca, U- -41-tLl�.. <br />EH230038 (revised 12/31/07) <br />