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Y <br />ENVIRONMENTAL HEALTH D PARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # 1 C U A, 4 (.T0 Ad f(6 <br />AFacili <br />C <br />Facility 'Name Phone # <br />� <br />Address S-05-- A(. W A/ 14 S T W a C A <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator G f I STO(> W Or(Zr, <br />Phone # S[0 - 6314- r S 0 0 <br />C <br />o <br />Contractor Name q LTO A F_K o xL6 tR c <br />Phone # 116 <br />T <br />Contractor Address , D, (j X 10 Z A- . S r o <br />CA Lic # <br />6 t 7 3 Jr Class a B, N 4 L <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number S E@. -r,4 {�-p <br />Expiration Date <br />Q <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />I <br />/A.00 o <br />8 -'1, — , <br />A <br />N <br />K <br />03 <br />$ 000 <br />q t — b✓S <br />❑Approved VApproved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name WYV� �DaaAAA^te jo <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 HE WORK FOR WH H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." —� <br />/+ <br />Applicants Signature Tifle t� 8IlZ� 1� Date i.0 <br />13ILLINU INt-UKIVIA 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 parry must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME TITLE PHONE <br />ADDRESS <br />SIGNA <br />EH230038 (revised 8/8/06) <br />1 <br />