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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 <br />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 # <br />A <br />G <br />Facility Name Ne L �C, �:� {�(s, <br />Phone # ct� 3r C. <br />Address I �,''� .L�.t �� C > L'V �R' C Y A e)-_) -C' 11 <br />T <br />Cross Street <br />Y <br />Owner/Operator ACL <br />Phone # <br />C <br />Contractor Name �C ._ i r ' I <br />Phone # `j% 7_ (4 L4 (r Le I cj j <br />T <br />Contractor Address LD�7 . Q �,E 1k c)5L,5 <br />CA Lic # ? C -3 ��; 5 Class (�, � A <br />R <br />_�} <br />Insurer ��� [1�`�� ��,1�' �C..t' <br />Work Comp # C) (7C!Q 4 i• 3 C <br />A <br />T <br />ICC Technician's NameIC�ICL>ICYY [��j <br />Expiration Date <br />R <br />ICC Installer's Name ��I���1� `❑��W)ti�—'� <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />1vas�e �1l but Rc �,cLn L`-er,�r <br />C�`C` <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <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 />\ l L 1 <br />Applicant's Signature '\ litl.i�l (I Title ~�'�1�(y�L( 1�-% _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 ���CC�L �C�T� ��t`� —TITLE ����1�_1� PHONE# <br />ADDRESS l y5r-pSC' CR 1— C4CL� <br />SIGNATURE I DATE <br />EH230038 (re6sed 08/1 <br />2 <br />