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1 <br /> ENVIRONMENTAL L T T <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# r4%r.,S <br /> APhone# _ `� <br /> O Facility Name 'T'q--'I'° 65- <br /> 1 Address - 'A t. <br /> T Cross Street L; t® <br /> Y Owner/OperatorG11 , �"(- Phone# I - (� <br /> oContractor Name I/�G" Phone# 1(��- 1Kab <br /> 0 <br /> N Contractor Address 6141 $` is CA Lic# 2-26493 i If <br /> T <br /> A Insurer f 5 "g- Work Comp# 2"`*P415-1 <br /> T ICC Technician's Name Expiration Date C)4-01-13 <br /> R ICC Installer's Name r; ° 10a 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 <br /> T ; `n25-,tXO 0al —elk M3 <br /> N ' jieSed! 1113 <br /> K - S e <br /> iesep <br /> P ❑ Approved XApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A / <br /> N Plan Reviewers Name Date <br /> tj Lr <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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title PH 166ALOlel Date Z <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 Clk r' S r — - TITLE_ PHONE# 6) - <br /> r <br /> ADDRESS I3 I . % <br /> SIGNATURE Z1, DATE ®(_ZZ/ <br /> EH230038(revised 02/20/09) <br /> 1 � l � <br />