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i1hEDD <br /> ENVIRONMENTAL HEALTH DEPARfk <br /> SAN JOAQUIN COUNTY JUN 1 9 goo$ <br /> 600 East Main Street,Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENT HEALTH <br /> R i i <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 XCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name 51hG11 # 13Co1$la;Tr GJticll 6 Mini t12rt Phone# Zj9q-$56-7G0$ <br /> IAddress <br /> L 3725 Trar-x blvd• TryG <br /> TCross Street 1-2-05 (on-r-ar-p> <br /> Y Owner/Operator Shell Oil G,p, Phone# 310-ei&-220l <br /> C Contractor Name AW& rlZint-1 lar ce, (atfin: t'la We, g - <br /> hr.�n Phone# d0 213-6038 <br /> T Contractor Address 3224 "to-n,21 Qkw �j�ry{a �Oba � CA Lic# 312B44 Class '�� Q C-10, <br /> R Insurer <br /> A 1Zeelwotad dire Q GaSu91Ins, fa. work Comp# 07A35050 <br /> cICC Technicians Certification Number <br /> T ' S 25 4-75 UT Expiration Date <br /> Qnsaer's Certification Number <br /> R ICC ItllCti5252032-U I b 5250O10- U I Expiration Date <br /> ( <br /> re-r 2"'- Chemicals Stored E� -}jn k.,6Tank ID# Gh2nT, Tank Size Currently/Previously Date UST Installed <br /> T I (log "J� 12,4to Ur►cadcd <br /> A {# 2 (7Ct) 1Z XD urltzd <br /> K 3 C?lo) 2.� Unleaded <br /> #q 710bo 17►ex <br /> P ❑Approved / pproved with conditions ❑Disapproved <br /> L S Attachment With Conditions) <br /> A — <br /> N Plan Reviewers Name Date <br /> 1 61 <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." <br /> Applicants Signatu gu,6exl1a1{ of Able flat1t- Title I_fD f. Date /�O/08 <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 /> � �w <br /> F-` NAME alq-j C�2r►k-0 �Of�Ptjf*4) f <br /> TITLE �d�• ' �'If- PHONE# �07-7�eS"l Abu <br /> ADDRESS 1137 0- 04>0t -11 51VG1• uv-Aa GA 61+154- <br /> 7 <br /> 1 154- Z. IZ+YiV10 @ .GOtM <br /> SIGNATURE --Z"ZV <br /> VV <br /> lit- vvvv EH230038(revised 12131/07) <br /> 1 <br />