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ENVIRONIVVNTAL HEALTH DWARTMENT <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 (COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name L AeVr-0.0 .#h ao t 76 ( <br />Phone # f 8 �— p1-7 y <br />IAddress <br />L <br />' <br />1103 M 41 N snz&ZFr PlAv -C.4 <br />1 <br />T <br />Cross Street W` I Z D <br />Y <br />Owner/Operator C ft01j 0C C01AI F A-" <br />Phone # Zo 8 Z -"$-- O 1 7 <br />C <br />o <br />Contractor Name GLe-rz fzyn �ti� , <br />Phone # a 63 /-i3a� &Z 7. y <br />T <br />Contractor Address 7 Sluiz Com-[' !,,,J* , ,00gG� CAS <br />A <br />CA Lic# Z2D7g3 Class s- ce/ <br />AInsurer <br />S --a _ ,J <br />Work Comp # 30S 2ao <br />TICC <br />Technician's Certification Number SZSc?41elZ _ V <br />Expiration Date 05 <br />R <br />ICC Installer's Certification Number 2t-ci y C Z,—U 1 <br />Expiration Date Z Z0 p�j <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />l) L SOS — ect <br />Lj 0IGAroU.s7 <br />r/ 4r5vc'.)a I_., <br />ICU ►v V S -' <br />A <br />N <br />K <br />P <br />Approved I' pproved with conditions )Disapproved <br />L <br />(See Attachment With Conditions) <br />A N <br />!Z � <br />Plan Reviewers Name-1Date <br />------ -------z/ <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 AGENTS 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 OFTH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />� <br />Applicants Signature_ <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 />NAMEGL-1jLbY2-R`ft �-SNC. RSD W 1304.V TITLE. k4tj&ZCiM�Ar�AG(nL_ _._ PHONE kgto 131-f 1co vzr_14_oelq <br />ADDRESS 7_1<I0 _G OL[--�i <41-m P >/.I✓v_ _ 4 f-70 _ A'n:G ko t - 6h. 9 547 O <br />SIGNATUREU� <br />EH230038 (revised 12/31/07) <br />1 <br />