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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 REPAIR/RETROFIT ISI COLD START <br /> F EPA Site# Project Contact&Telephone# Ro_ w u aLLt <br /> A <br /> D Facility Name C;tkk,�vcvk, 0—mk Phone# ao <br /> Address <br /> i q(av VJ TIV-&e A <br /> T Cross Street c1b14"41 Q(k� <br /> Y Owner/Operator A--C" Phone# 0-V -3t?1 <br /> o Contractor Name Z S Eta S t-C SLS T, Phone# .{C ' `X1-1 <br /> N Contractor Address <br /> T fR�C© (kviw,� $J �/� gSLtq- CALic#�/' -(� Class C(cl�-wo Z <br /> R Insurer p 331 C �( <br /> A C` �' '� ��CS`�•e- C O . Work Com to 6 Q(# • " <br /> cICC Technician's Name 3 l ao u <br /> T `� Lp Expiration Date <br /> RICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> v <br /> P ❑ Apprc ved Approved with conditions ❑ Disapproved <br /> LA(See Attachment With Conditions) <br /> A zz(v�► <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WILHSAN AQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENTR 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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /{ <br /> Applicant's Signature JjA QA , �Li'iitler L La, -(`'`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 /> ' �� �( / rr <br /> NAME �O-Vc �1� LvL <br /> Etl[-Uk j TITLE ��chrQ. 64CL-,V PHONE# 4O'�: <br /> ADDRESS �� ��Ll IBJ '� 1� J LJ ( I <br /> SIGNATURE OAA—&,t,&. v' �IJ -7o ( �� DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />