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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # ;,0 9 - C/ S ( - O (, ( 3 <br />C <br />Facility Name (C LPr G (,J�S� f'Y1Z I A <br />Phone # <br />� <br />Address 66-(2Em O ( STD C " lga 19 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # 1;Z0 �7 —�j $-( _ (� I <br />C <br />0 <br />Contractor Name (^�� A" <br />Phone #9.537 9356 <br />N <br />T <br />Contractor Address ( L.R v v <br />CA Lic # T 3 g Class �` G ( 1�y0 <br />A <br />Insurer <br />Work Comp #A)!jZ41 `/340 330 I I <br />T <br />ICC Technician's Name rY11 Ctl� �-1 C_ <br />Expiration Date 3 _o?_ ap (y <br />ICC Installer's Name �(S,C M(T�kk� L.0 <br />Ex iration Date <br />ROR (S <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />K <br />P <br />❑ Approved ,Approved with conditions ❑ Disapproved <br />L <br />N <br />/� See Attachment With Conditions) <br />Plan Reviewers Name Date K, <br />APPLICANT MUST PERFORM ALL WdXRK 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: N 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." <br />ll �r� p <br />Applicant's SignatuJ! tet\ rl w i0 L I�ri Kl`(tL le PtG Et l T- 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 parry must acknowledge this <br />responsibility for the billing by signatureanddate below. [ <br />NAME � � V'c-nP w/ . TITLE PHONE #--0. OI - 5 7-93 g O <br />SIGNA <br />EH230038 (revised 10/30/12) <br />L-Rt:>A- A>j "--\- .�fSZt �S , CR , (1 S -d7 <br />2 <br />TE$?-(� - (3 <br />