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• <br />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/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #A116, 76, aj (71,42RM-369 <br />A <br />G <br />Facility Name L L -t- L Z 70 544 S.-. Phone <br />IAddress <br />L <br />/ Zc�q <br />ZC Z �� vt t V7 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator �, �-T`eeA , Phone #l0Q/0 -267-o'zot <br />o <br />C 6"%D-3,cContractor Name E�i'one # <br />tf �1 <br />T <br />Contractor Address 2151 C-) r + , , <br />CA Lie # �! �� Class op C3 �, <br />R <br />Insurer <br />Work Comp V 0O(� " 17-7 11 <br />C <br />ICC Technician's Name <br />Expiration Date - - <br />oICC <br />R <br />Installer's Name <br />��EC` <br />Ex (ration Date <br />P <br />Tank system work area <br />1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC etc.) <br />A <br />N <br />K <br />_. <br />P <br />❑ Approved �' 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 <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 />C©nl�y�P�7YL� '�"l <br />/ <br />Applicant's Signature Title ` Date <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, r /! O1 ��5 TITLE ly��/'4�iK_ PHONE O/(% A3/ 0 <br />ADDRESS 3 (�I �� v Rr-(�� l�J1_/ Vli. �a�}L \[ �1} IVIC. <br />.LII' <br />SIGNATURE t�[�------ DATE <br />EH230038 (revised 02/20/09) <br />11 <br />