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0 <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 KCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # I CIN A X L WA, T—o,-.1 <br />L <br />� <br />Facility Name Q U ( VL S T--0 t, <br />Phone # <br />� <br />Address Z Z W E T- LS '(-0 C IG T"o /� 9 S 2 0Ct <br />- <br />I <br />Cross Street A. vU VA TO g - <br />T <br />1F2 W <br />Y <br />Owner/Operator Q,j (v- S ro p W p.K v- &vvr_ <br />Phone # g j p - 6S-4- Sso 0 <br />C <br />Contractor Name i�Lr4►� <br />Phone # <br />9�6o <br />T <br />Contractor Address 5r0 X r 0 2 S U% • S A4, --v Q5 6 R ( <br />CA Lic # Z 3 Fr Class A. $ , A -AZ <br />A <br />Insurer ST A -:T- E F- I.) P-Ll� <br />Work Comp #} t 3. 0 QO q Z 4- o ff <br />C <br />T <br />ICC Technician's Certification Number SEE A-rT A-Gdf-lvp <br />p� <br />Expiration Date <br />R <br />ICC 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 />®I <br />! i0 %C <br />S 0 G, tic. <br />Ll JuLe- <br />A <br />N <br />K <br />P <br />❑Approved proved with conditions ❑Disapproved <br />L <br />ee A ent With Conditions) <br />A <br />N <br />Plan Reviewers Name Date d <br />APPLICANT MUST PERFORM ALL WORKIN CORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL H H DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR ICH 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: N CERTIFY <br />THAT IN THE PERFORMANCE OF HE WORK FOR WHI H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title CDate ( / <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 byrsignature <br />�and date below. <br />ilp <br />NAME V Y � (C 14 A-E- ( 'ph C 1 � TITLE CQ'�j?, AA--rV A,- PHONE # 3 *3 - (l S- <br />L <br />ADDRESS P. O` g ID )( H O Z i W- S. 1 v c A 9 s-6 4 I <br />SIGNATU <br />EH230038 (revised 12/31/07) <br />1 <br />