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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 <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />D TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # A4"N`Z> 6,0%vcc u G6 <br />� <br />Facility Name TESD I <br />Phone #-2o c(- 36 k =-S. 1 -% <br />Address �-l;� �; , I �c/t'[ 1.M �ct� L.;�, {�? Lp ➢ �t s �d J <br />T <br />Cross Street S �;L, r -t �► <br />Y <br />Owner/Operator • �Ne� j�,l �y{��� �;,J , <br />Phone #-,--I io-- (2 <br />C <br />ContractorName I L�LC.�J r5 �O ca v ��,,�j 1 tJ C <br />Phone # <br />0 <br />tJ y-�t , <br />T <br />Contractor AddressJ-(-SS%' S"iebcv> c,l,wlc�v <br />�2rLic# ` .�2R S Class /� 13 ��1� <br />A <br />Insurer �� 4C_ Cot-t.n, S , :- h `r G <br />Work Comp # -Z) r3 C)7.5&S — <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />0 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 teak detector, UDC 112, etc.) <br />T <br />S, ~,'l �. QS-1rd���t�i <br />01J L, Gc) N <br />N <br />K <br />,.:c+tLLC t'S'h�viP <br />1 Ta -'tAN> v 1L S <br />P <br />❑ Approved with conditions ❑ Disapproved <br />L <br />&Approved <br />hment With Conditions) <br />AAC <br />N <br />Plan Reviewers Name Daten� <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 0 ARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHI T IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALI IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WO OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature TitleN&IG4—< T-00- f' S��z� Date` jL+221.2- 11 <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 FV 1 Syl-+ & I N VL X1{.) (A- �YTLE h650tl� '(✓' —f— VS' �IC'HONE # ( b I - 24-50 "`�-�l ?C.) <br />SIGNA <br />EH230038 (revised 08/1/11) <br />2 <br />►30-0 <br />