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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 />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # m' K - —50E44ce. <br />� <br />Facility Name L -L- a t— I %A A <br />Phone # a0c? <br />L <br />Address <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator v(« (AGEc�J�,sT- c�nec2�s�► <br />Phone#avQ-95) — /ss If <br />C <br />0 <br />Contractor Name� L�,� �rn �� <br />Phone # 7 _ rJ _ � 3 7 b <br />TContractor <br />Address a CA Lic # 3 0 � Class <br />R <br />InsurerWAv S VS) l�S G� , <br />Work Comp # w p p t <br />T <br />ICC Technician's Name ( A-tA M I TC A tLL„ <br />Expiration Date,3-0—aafq <br />° <br />ICC Installer's Name p1� <br />('�{-��,L\ <br />Expiration Date <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 />T <br />WEkn(CJ - N <br />QOO <br />v Se. <br />A <br />N <br />K <br />P <br />❑ Approved�Approved with conditions ❑ Disapproved <br />L <br />N <br />(�nttachment With Conditions) <br />�-2 <br />Reviewers Name Date (� <br />Plan <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 FO WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title Ar=*A r Date <br />bILLIN(i INI-UKMA I IUN: <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 signature and date below. <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />TITLE PHONE # <br />1 <br />TE <br />�Z <br />