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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/EYR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone 0 wn 6 <br />A <br />Facility Name GNrCIG K <br />70SA"1y8 Phane# 2091- 9S7-.2900 <br />L <br />Address 320.2 La, j4ammec <br />Larie S fi c t n95-20-2 <br />I <br />T <br />Cross Street <br />Y <br />Own;er/operator : n F z0 9 - 7y0 - O is6 <br />o <br />Contractor Name <br />Inc. Phone NY 92s -s S/- 7sSS <br />" <br />Contractor Address 3/yp 60101 C& <br />Qp, SV:tpi 7 CA Lie # 220793 OIMA -1-tecAerl <br />R <br />Insurer 5 tt <br />,'o FLnej Work Comp #do0 os- - 2 Cog <br />T <br />ICC Technician's Name <br />eL49 Expiration Date 6-2-11 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Q.& 87 p1pbg sump, 91 Galt dMnclor, UDC 12, Mc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />112, 3 ,. S 7VnArn <br />✓n n w.• <br />A <br />N <br />K <br />P <br />❑ Approved <br />Approved with corxMions ❑ Disapproved <br />L <br />(See Aftecbmerit With Caxiftns) <br />NAD <br />--, '�� AD <br />Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL W K IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATKINS OF SAN <br />JOAO UIIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: M CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 13HAtJ- NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SL49CONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNA." <br />Appica * Sign adm9 n^— <br />TIIN (` V a r%e! DM9 Z Z 1/0 <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 4-ettler- %jan Inc. TITLE Con�trevio,, P4t0NE3 9?S-SS/-73:S3- <br />ADOREss 3/`lo G.dld CGr-rp Ar. ScI.'te- 17v, �anc�Mo N!ordoy9 , Ca. 5�S'NS7v <br />SIGNATURE L: _—_ DATE 2 12 Z� 10 <br />1 <br />