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ENVIRONMENTAL LDEPARTMENT <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 EPA Site# Project Contact&Telephone# (_G2®L.4�) t.el®q - ® a2 j� <br /> A A QT T <br /> C Facility Name PAc,Q-,L Phone# <br /> I Address 1'2. 1 <m -t- <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator A--+**,-T- Phone# <br /> 0 Contractor Name -T-a,k- En.'®r�,r,r vv� v. Phone# a`�� ��9- `$2lp <br /> 0 <br /> T Contractor Address ®® 2 a T'v C��-.�2e17•- CA Lic# 51a ®gF� Class �' HA <br /> R Insurer <br /> A Z,o e-®dv-- /� '�r�"v c�� , C-O Work Comp# W GQ11311 4So2_ <br /> 0ICC Technician's Certification Number SZS'2®to3 - t.� Expiration Date ci�12' 2009 <br /> T <br /> oICC Installers Certification Number <br /> R ' S'Z-S 21to3 - LA-` Expiration Date y to Loo 9 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 12\k4 Sk c\®c��t ® ® Zoo 1 <br /> A <br /> N <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date C Cj <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 Signature Title o.,..a Date 1Z—2'L—a <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 f `+\.e�N TITLE-V�kc_c_.—W`Gvea SscLPHONE# �G`+�� tp Co Cl -`b2-ko <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />