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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 /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name (��'['�(Z (-O O FOO N fz•L_ Phone# aC5 - - S8( <br /> I Address 303 <br /> L oZ (�At'� LOO t�Z�Ac) cR . 9 s ao s <br /> TCross Street <br /> Y Owner/Operator -RA4,4101y G QE w ol.L_ Phone# 9- 6�o_ 5 g((o <br /> C Contractor Name _ pA[- E, yM �(pm ,N Phone# <br /> 0 <br /> N Contractor Address 5 Olo CALic# 0(? CIassC�( - (�-y <br /> T <br /> R <br /> A Insurer Work Comp# <br /> T ICC Technician's Name I't-C,( EL,L,,, Expiration DateI( -30-o�0(� <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed l <br /> T m U m— —?b S. <br /> K <br /> P ❑ Approved ,Approved with conditions ❑ Disapproved <br /> L (See Aft hment With Conditions) <br /> A /n <br /> N Plan Reviewers Name Date �? 2_0 /Z f 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN C 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 <br /> TO 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 /> Applicant's Signature kL�- C. \ Data IRC) <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. ,,�1 2 <br /> NAMEYCJ1r\ Mct'f►'lFi/ — ��'��_ /�c lMA C,0- TITLE o4icc h�Gt�6le, r PHONE# �0— <br /> ADDRESS 0 D(� INTI w\O fTV C- S l�(� ' / E07 <br /> SIGNATURE r<^% � Yf L 2�� DATE <br /> EH230038(revised 07/22/10) <br /> 2 <br />