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. , <br /> � w <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 EPA Site# Project Contact&Telephone#{U/PI4 A ,4 a Rt Q!6 3�3 -//f <br /> � Facility Name MAMCll.A L A?L E qI-(o Phone# S(}3 -1-3 3 11- <br /> I Address z, :�C t Wi A r,L C W G 9 . s ro C(L't-,0 P-( S z 1 9 <br /> I Cross Street Q 0( <br /> T <br /> Y Owner/Operator AQ. Lf�rL- Phone# Z05a- <br /> o Contractor Name L _ `f ��,�� C- Phone# <br /> N Contractor Address (,r,f s pec,C-ID C Ar A F., ( A Z <br /> T e,rX /oZr S'6Rl CALic# (p (� 2.3g Class <br /> A Insurer C,-rNrti, FvMt) Work Comp# -�J3000qQ2} 0-1- <br /> cecnician's Certification Number <br /> T ICC ThCtitis E C A,1-T ArCI'r{-" Expiration Date <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T b I S-IL . A-S ` 91- <br /> N V— <br /> K O31 Z (L ►� �L <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WO 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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE WORK FOR ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title C 9'�tZ Ater&fi-- Date ® 6Lo <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 Y " t C(� � C <br /> a' <br /> - W �r(.1 B t.( TITLE B^LT-2 AL-Orl_ PHONE# 2((o -3 }3 - //S 7-- <br /> ADDRESS <br /> —ADDRESS O ' 'G O K 102'9' (,Q.J - S A,-�,o 4 C A 9 S 6 4 l <br /> SIGNATURE <br /> EH230038(revised 431/07) <br /> 1 <br />