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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 <br /> 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 EPA Site# Project Contact&Telephone# A y',¢a Ir <br /> C Facility Name Cc? ] r 0ulo 7(p Phone# c?% - 3 - 3� <br /> I Address �'J� f���r7-fr C'jub !✓its S' ec%fc rt �75z -'y <br /> T /% <br /> Cross Street -rno c L4 ;, R <br /> Y Owner/Operator 04 /; Su J Phone# <br /> CContractor Name r"r !lYt �F f('o l u tz r Phone# 1?vA5- Lffr 2 - `BOG c> <br /> O ) /�lQi/1� ItCtI?C�, <br /> T Contractor Address j"& lam/ o rvl r//l S 1, Plea S a r)/t,,` CA Lic# �qlj 1.1,9 Class e&I !'-�U <br /> RlZr7Sct✓'ttr�L�ci Work Com # '9S73G r,SS <br /> A Insurer tntd Leahir <br /> T ICC Technician's Name 6r{ •c, C7 e-/y-7- Expiration Date tufa//L/ r 3 <br /> R ICC Installer's Name C7r-e e, 6 e H Z Expiration Date 0i a <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T541 j-w ell cG'fa q e r �'tse,/s --r c <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N ?S�Z / <br /> Plan Reviewers Name Date f <br /> or <br /> APPLICANT MUST PERFORM ALLA40RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS 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 /> Applicant's Signature �C�/ <br /> t&_,,-"1•" �w dl-�"`�� Title �Y�' Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME /�a! Ire-A I7etiS hi TITLE 05-4) PHONE# <br /> ADDRESS j7(p lu t fetSat)4n 64 9V3 � ¢ <br /> SIGNATURE ��- �'(xZ L.c-f DATE C j 0 j l <br /> EH230038(revised 07/22/10) <br /> 2 <br />