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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 /> 14 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#�nc4i krown <br /> A <br /> D Facility Name ( L O D O Phone# 2 <br /> Address <br /> L S C LoVI-S e- /�V�' <br /> TCross Street <br /> Y Owner/Operator QP//-`I('(_v SCD t t L. s tci r Phone# ,S L� b 2 / U 7 7 0 <br /> CContractor Name Phone# 2 j <br /> o G trier-(z an InL 9 <br /> T Contractor Address 3/`40 ( IJ Cu o, pr SO �1 17 r] CA Lic# z Z 7th Class g y taC f�eo <br /> R Insurer Work Com # C <br /> A StC41e COr-rp n .on %—line!' P �c>c3c3 C 1 <br /> T T ICC Technician's Name C '`, S to pher— rnTon Expiration Date <br /> R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 Aping sump,91 leek detector.UDC 1[2,etc.) Installed <br /> T ;j) S�1r� nJfnowr� �'� Cct Ga n sown <br /> A <br /> N <br /> K <br /> P -i Approved Approved with conditions j Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N 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 <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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> i <br /> Applicant's Signature Titfe _ _. /'r�.`, i= Dete < 7/c% I <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 Tt jet-- �-yC411 !nC TITLE Cent(-C,0 0 C_ PHONE# �2S S�sl �JJ S <br /> ADDRESS 67`l7 S- Nr,-q [bUc'-1 SU t e 7 <br /> SIGNATUR � lLct rid`l QrOw n DATE 'I Z 7 r D C,1 <br /> EH230038(revised 01.120109) <br /> 1 <br />