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i 1 1 r <br />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 DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # hI c4f A Ivt (//A c -row y(6 3 43 - <br />� <br />Facility Name ZZ } <br />Phone # -S-30- T85-- 0 c/0 <br />� <br />Address 3 3 0 0 (A/ A --r- fit- C o o 2 S -Fo C IL T -o r4 9 S z o S- <br />I <br />T <br />Cross Street 2 0 2-T— V E_ <br />Y <br />Owner/Operator <br />Phone # 5-30- $ k S - C /0 <br />C <br />Contractor Name A L 'rp,t.( � C 1 N, E v R r,,[ ti � r _ <br />Phone # y� 6 - 3 � 3 - // S L <br />T <br />Contractor Address 8o)( to Z r ()J, S ?T6 q( <br />CA Lic # ( r -4- Z 3 Ir Class A, <br />A <br />Insurer -T- A-- -t- F j K&P-) <br />Work Comp # 13 X19 1-+ Z 0 0 & <br />T <br />ICC Technician's Certification Number S EE; A-T-1-A-Gb{-pV,;� <br />Expiration Date <br />RICC <br />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 />o f <br />o <br />7Z F.b e L 64 &-t- <br />U tt V— <br />N <br />2� <br />/ A !C <br />C L is --t <br />kr?- l KiS <br />, <br />p <br />K <br />P <br />❑Approved j proved with c itions ❑Disapproved <br />L <br />(See A ch ent I nditions) <br />A <br />N <br />Plan Reviewers Name2:2�Date 3 Z I jQ Z <br />STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />APPLICANT MUST PERFORM ALL WORK ACC D TH SAN JOrRINSUBCONTRACTING <br />�ONANCES, <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH P MENT. OWNER OSIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH T PERMIT IS ISSUEDANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION WS OF CALIFORNIA." CONTRACTOR'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." G <br />Applicants Signature Title C A 2 oR-- Date <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 O I C IAA-tt VV tT (- 0.0 TITLE C 10 PHONE # <br />ADDRESS S A -e �d� C f+ % S1 6 q <br />SIGNA <br />EH230038 (revised 12/31/07) <br />1 <br />