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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 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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# S <br /> A <br /> C Facility Name � �� `� � —� �1pq �-� Phone# <br /> Address Z`-1 w• C\ S-�rz A JLt-' C.A <br /> I Cross Street <br /> T \ <br /> Y Owner/Operator Phone# <br /> C Contractor Name '—�-- _ ` Phone# � to <br /> g5 �- \o Cl C) <br /> T Contractor Address t t 2`� T � � CA Lic# S e$pq 46 Class A,-!t, C_%a/ S33 <br /> AInsurer Z �� '"'„' o �o o„e. ' C.r'. S Work Comp# ti <br /> T ICC Technician's Name V--- R�?_NZ-Q 0 Expiration Date <br /> QICC Ind <br /> R VEtol=� Q.oOT L�2T 1 Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T --- <br /> A <br /> N <br /> K <br /> P ❑ Approved ,Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Q22z2ftDate Jc, — <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 AGENTS 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." p -rte <br /> Applicant's Signature ILN a,_ ./�.� ._�� -Data —®Ot <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 X',(\.eL a S c�a o TITLE i�vo r�e� _WRHONE <br /> ADDRESS k\2-4�D _d�a ��2� .�.t- „�c�o ct rV.�fa. Cak g S 14 Z_ <br /> SIGNATURE DATE \O —\-S —O q <br /> EH230038(revised 02/20/09) <br /> 1 <br />