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From:ER VINE 209 541 1694 03/27/2015 11:31 #070 P.002/003 <br /> From ER VINE <br /> 209 541 1694 03/11 15 08:14 0058 P.002/006 <br /> AF-CEIVELENVIRONMENTAL HEALTH DEPARTMENT <br /> MAR 2 7 2015 SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> [7NVIRONMEN-1, Telephone: (209)468-3420 Fax: (209)468-3433 MA 2, 10 <br /> APPLICATION FOR UNDERGROUND STORAGE TANJ(*,�j yt <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THI;7RMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PER 11 OPE BELOW: <br /> PIPING <br /> VC <br /> 0 TANK RETROFIT NG REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT LD STARTIEVR UPGRADE <br /> 7? <br /> [ <br /> F <br /> A EPA Site# Project Contac!&Telep.lione 41-:Ao e 3 7_4 <br /> C Facility Name nay rT <br /> L Address I (:E-,>7 Lo. L 0�p <br /> Cross Street <br /> T4-3 <br /> Y Owner/Operator Fpc"�&TT Phone# <br /> oContractor Name C!pL_� Phone# o 9 <br /> N <br /> T Contractor Address- C?S A Lic# <br /> R Clas. <br /> A Insure(/"-5-kxz�C4 to. -6F TIAE, Work Comp#Wf7j_ !DaI4 <br /> C <br /> T ICC Technician's Name M Expiration Date <br /> 0 - <br /> -R ICC Installer's Name Expiration Date <br /> (.e 87pi Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> P.9 W11P,91 1112k,106dol.UDC 1,2,W.) Installed <br /> A <br /> N <br /> K <br /> z Cil <br /> 1 <br /> Approved <br /> Approved with conditions Disapproved <br /> L (Se <br /> 4tachment Willi Conditions) <br /> Plan Reviewers Name E Mum —Date— <br /> �APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUiN 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 /> 'WORKERS COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY <br /> 1THA7 IN THE PERFORMANCE OF THE WORK FOR 1 HIGH THIS PERMIT IS ISSUED,I SHALL.EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.'— <br /> OF <br /> Signature fie Date <br /> BILLING IINFORM4TION- <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyono 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 /> NAME�.L_t:C-_ -� <br /> Ck�)fa TIZ4* PHONE (2, <br /> o') <br /> ADDRESS Gq , 955 7 <br /> SIGNATURE DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />