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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br />UTANK RETRORT UP*nr4G REPARIRETROFIT UUDc REPAtR/REMOFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # t c oiD9 - 1pI - to ,339 i <br />A <br />Facility Name ., <br />'' •k -p Phone # q — 41 (pa — 7 6 <br />LAddress <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator NC(h <br />Phone # �C.Iri d <br />Co <br />Contractor Name L' L <br />Y1 1'T GSC `C, <br />Phone #Q 3 % <br />T <br />coni-acbr Adaress a S3 S Gc� r' w ct r,•� CA tic # (p& 0,0 C <br />R <br />A <br />Insurer ✓Q n 41>r OO•.n <br />work comp # Q 065 O 17'l <br />T <br />T <br />ICC Technician's Certification Number <br />Eviration Date <br />RICC <br />InslaWs, Certification Number <br />Expiration Date <br />Tank ID # <br />Chemicals Stared <br />Tank Size Cunentlyiiteviously <br />Dare UST Installed <br />T <br />A <br />N <br />K <br />P <br />UApp ved <br />�ved with conditions UDisapproved <br />L <br />( Attachment With Conditions) <br />A�1- <br />!G�'�U4/ <br />N <br />Plan Reviewers Name <br />Date I a <br />APP3KAHTMUST PERF015XALLfAIGWLN- <br />INCE- WWW .SAN .XkAa OOLWYDgPNAp�.S7AZ€lA4A�S:M[iRLXESAW_REGtAJ1TtONS;OFSMI <br />J0AQM COI i Orf E W ROWENTAL HEALTH O ER OR LK8ISED AGtWTS SIGNATURE CERTIAES THE FOLLOVJM: 'I CERTIFY THAT MI <br />THE PERFORMANCE <br />OF THE WOW FCR VMK:H THRS <br />PERMIT IS M)ED, I SNAIL NOT EMPLOY ANY PERSON IN SL CM A MANNER ASTO BEOOME SUB.IECT TO <br />V40RKER'S COMPENSATION LAWS OF CALIFORNIA' <br />CONTRACTORS HRW OR SUBCONTRACTM WWATLIRE C 3RTTFIES THE POLLOYMOG: 'ICERTIFY <br />THAT IN THE PERFORMANCE CF THE W CORK FOR WHICH THIS PERMIT IS LSSLED, I SHALL EMPLOY PS?�"4 SU3ECT TO WaW7 ERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Amts <br />-g-tk <br />.L.YUit� �oDra�rnal /l - A7 -D7 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff fine 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 adamwledge this <br />responsibility for the billing by signature and dale below. <br />NAME �1�`JC✓(oyW;C17 <br />ADDRESS�3�S /wi I A l.�G w�- U�r S 40 C-k4t N Ct Soho r <br />SIGNATURE_�i <br />EH230038 (revised MMS) <br />VA <br />