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0 <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 /> IS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> T <br /> ❑ TANK RETROFIT PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# J s' ,f,1 —� ` <br /> A <br /> O Facility Name A ® QD0P C POa Phone<26-Z) 4,69-®3 0 <br /> � - AIM Address / 2-0 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator j&4&Ljjkj /C115SPhone 1 — j 4 <br /> oContractor Name Phone c/ <br /> T Contractor Address fig CA Lic# Class C 6/r , 3 <br /> AInsurer ~' _ -f Work Comp# Pj a 70 ° <br /> TICC Technician's Name 6 Q ' Expiration Date /® f <br /> Q ICC Installer's Name / 6� ( Expiration Date <br /> R ZZW <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 /> T 7 P® ® s ,� S� / l 1 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ DisapprovedO / <br /> A ,L (See Att chment With Conditions) 0 `°e"''s <br /> 1,7 <br /> N Plan Reviewers Name Date 2610 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ��yy <br /> Applicant's Signatur Title 6: ate V <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 /> responsj,bitRty for the billing by signature and date below. 11 <br /> NAME9riF TITLE � PHONE l <br /> AbbRESS a / '� J E s Z4 D <br /> SIGNATUR DATE <br /> EH23003 d 02/20/09) <br /> 1 <br />