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C <br />ENVIRONMENTAL EL EPA T E T <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 l=ax: (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 />0 TANK RETROFIT I:1 PIPING REPAIR/RETROFIT /UDC REPAIR/RETROFIT /COLD START/EVR UPGRADE <br />F <br />EPA Site # --� Project Contact & Telephone #X S p%j(rt i%;1-�IiR �a�►I :2 <br />A <br />G <br />Facility Name "�"er m. V jk� t Phone #,Z 10 •// Z <br />�. <br />Address Ho I G�jes 1464Y"V% CA- 9 S:2 -41C' <br />Cross Street L.tFjE AVW_ <br />Y <br />Owner/Operator f-j� S-Q<;.o �, aNu.y�r, 4, 44ert jt...Sk CO. .hone #,Z 10 7— 6Z — <br />o <br />Contractor Name [ S' INCA Phone 57-17IS'- <br />T <br />Contractor Address JS71S dq,*g �S �Z„ 919V0�ws CA Lic# GS'j, 7Gj' Class C-10, <br />A <br />Insurer 55�-k--Tr (. PLA9,I+�S. NQ «' <br />Work Comp # cl.T,7 -5S-1 t" — <br />T <br />ICC Technician's Name J-11 <br />Expiration Date Q 6(;6(;ZV Is <br />RICC <br />Installer's Name �p�� j �� <br />Expiration Date <br />Tank system work area Tank Size Chemicals Stored Currently <br />(te. 87 piping sump, 91 teak detector, UDC 112, etc.) <br />Date UST <br />Installed <br />T <br />1 �'acC / SSi N ir- CCi�— — ---- _._.— <br />__..____. <br />A <br />P'✓ <br />i?� S�°laNf�st-S w Nga^' tt*�Y <br />N <br />K <br />t Nis Art a.- iota! B ' V N <br />6!J VtaG�S <br />�.0b <br />P <br />i..... Approved i Approved with conditions �.....� Disapproved <br />A <br />(Se Attachment With Conditions) <br />i1(I <br />N <br />Plan Reviewers Name Date V <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 TV(S PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIF05 lA." 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 />i AA� <br />Applicant's Signature Title !�'!L Date to <br />7� 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. �J / 1 <br />NAME Ir t s £t+�GaN�V I TITLE AS6-15#PHONE # C �b+1 -,Z�3t�g?Q <br />ADDRESS�O "z�J +S�® c�4N C"C.C?«` 9'111E, 1V 4 � •. %- 5 t Se [ <br />SIGNATURE <br />EH230038 (revised 08/1/11) <br />2 <br />TE <br />>=13Q-> <br />