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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 />n <br />ITANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT I�ICOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # n4 I C N A. g L WA, (-T- ! f /6 . 3 4.) - /rs- <br />A <br />C <br />Facility Name (� U ( IL S -t-o P *- / 3 Y <br />Phone # <br />I <br />L <br />Address S Z s �� A rtn tnti r�rL. L T -C C16 " 1.l 9 S' 2 0 <br />I <br />T <br />Cross Street Af-L r CIii, n, S Z <br />Y <br />Owner/Operator 11 I S -C-O p W A -ft IG "--f5,—k r , <br />Phone # Sr o _ 3.:)- - & S'o 0 <br />o <br />Contractor Name C -r p,{ (� (►.( (7�(Z�„c(, T C _ <br />Phone # cb - 3 /l S` -2— <br />N- <br />T <br />Contractor Address 0 K i O 2 S" - S P �� 9 S6 q <br />CA Lic #/} <br />2 3 Class /� g {� A-2_ <br />A <br />Insurer r A Tt4� Fv Kx-� <br />Work Comp # I . q q Z -4 <br />TICC <br />Technician's Certification Number S N -T --T- <br />Expiration Date <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 />O I <br />l 4 Y_ <br />8 ;- - r, A,5 o r wL-R_ <br />U J•! 1L <br />N <br />K <br />0 3 <br />P <br />❑Approved S;Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <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 TO <br />WORKER'S COMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF HE WORK FOR WHIFH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />/ <br />Applicants Signature Title C OP -kW TZ At,4_VA-- Date I o 5 <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 signature and date below. <br />NAME YY l' GW A'*(_ �)/A' C, -FW TITLE tZ .A -C" &-- PHONE # GIBE - 3 �- 3 - 8 5- -L- <br />SIGNA <br />EH230038 (revised 1 <br />11 <br />F, 1) x " r z .f- c A, 9 S-6 t I <br />1 <br />