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ENVIRONhtNTAL HEALTH DaARTMENT <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 /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility NamePhone#s�,� <br /> Address 7000 rR c C*104 C-"I L 5, FY CcIL CA q :52--7a,, ( <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator ds�- kzzt, Sivi us, 'ba, kphone# Z-09 (® <br /> C Contractor NamePhone# <br /> 0 'C' <br /> N <br /> T Contractor Address 7-3 yo -7 -7 Lf ff 6 2 Class i3, p 2 <br /> ,d_Z)6jr _L4 to CL, CA CA Lic# _j,D 3 1)L(C <br /> A <br /> R Insurer Work Comp# t3 - 000 6 55,f-(l <br /> C <br /> T I CC Technician's Name J� -j�L4 Expiration Date 12 21,g2 <br /> 0 <br /> R ICC Installer's Name 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 A--n 11 Ld 0r SDa Ot -V 0-L7Y <br /> A <br /> N <br /> K <br /> P El Approved Approved with conditions El Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 0&2,7112— <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 PE 0 CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." Rp6t!_ <br /> (-) <br /> -QA e � <br /> Applicant's Signature Title 4!�—t V I—L r LALCI VL1 Date /2, <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 /> responsjbility forth bill' b t <br /> %I inF y si nature and date below. <br /> CiA L-G-i T-1 <br /> NAME 4--7�tj-/-7n �-OtjITITLE LL2 ry-t,,v-dA AAat1a-(,1-/-PHONE# <br /> ------L5 3 <br /> ADDRESS 7 5 to Ct-e % 4 U-36U c-A 15->k(b <br /> SIGNATURE—(= DATE 12- 0 -2-- <br /> EH230038(revised /1�111) <br /> 2 <br />