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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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DALE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT 'PIPING REPAIR/RETROFITUDC REPAIR/RETROFIT JUCOI D STARTIa "� <br />F <br />EPA Site # <br />Project Contact & Telephone # R&A4 WP- 40k-aa_W-3 <br />E <br />Facility Name V'QL' BtIX� Sk U < K4KZ RCLL,,f- Phone # --,o 9 , Y3 z •. 76 OR <br />yt <br />I <br />Address "T�,p�c "�ef3r -q�53-Tb <br />i. <br />T <br />Cross Street <br />Y <br />Owner/Operator j0f- t(aLL.Kacoak- <br />Phone # dog- �3 --tip% <br />C <br />Contractor Name Sev'Ul�� S{t - �1 s Ttpt ,�s Tvr <br />Phone # <br />T <br />Contractor Address b'� 0 QU 141V1 RJR- 4So-o-4c.4 CR JTJ4 <br />CA Lic # `F& J (S y ClassB wci ib <br />A <br />Insurer�gS S V � ,� e <br />Work Comp # 331 OCA ods 66 I <br />TICC <br />Technician's Certification Number 15736S a 75 _ LIT <br />Expiration Date <br />° <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # Tank Size <br />Chemicals Stored Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />r <br />P <br />❑Approved pproved with conditions I ❑Disapproved <br />L <br />A <br />N <br />(See Attachment With Conditions) <br />t I <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 TO <br />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." y <br />'y <br />Applicants Signature L4. , "� e L Date <br />BILLINU INFURMA I IUN: <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 <br />wand <br />� date below. r� r,� J z <br />NAME ���-��N �' U.�GLT�i('�IyN TITLE 1l0-ILLj-{-O't' (-W PHONE # 40� <br />3 ` �-'(PC V <br />ADDRESS (03 IS QV c CU.L /kU e S0.(,t AQ) c e '1 <br />SIGNATURE U.( ti L -L/ Lt4tiL�+L/L�.J <br />EH230038 (revised 12/31/07) <br />1 <br />AZ - <br />