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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 RETROFITPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Pif ,r.g <br /> � Facility Name S:35"fSS' 1)(,F t,-3*J 0Z �p� may._ Phone# 7 <br /> L Address 700 tV. r^ W. QpILMS two ft£o-c" CR.cr+,q.- <br /> TCross Street <br /> Y Owner/Operator G_jcp►er X.Clp" tnt.r.,A6FIIn�..lt' SPI. jrt"Wwb hone# i-m) 448 - 44,3-7 <br /> C Contractor Name dq £ut ,� ,, £Pq Ctf Phone# G7^ t}.8o0 <br /> T Contractor Address 2370 Mp►cj +xpa LOOT CA Lic# -7-74-802 Class Z e.G1026 p �.1 <br /> R Insurer p all-140 Work Comp# fl J <br /> A Mo►sP�pg MpvR 8. 00 S— <br /> T ICC Technician's Name ZAMtS PAS Expiration Date Sgpr 2,a,2-017- <br /> 0 <br /> Z,201 Z <br /> R ICC Installer's Name p ut krr►m% Cp�S Expiration Date Ste' 2c Zo 11 <br /> F rt va,�A sFsT- C <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved N5.6pproved with conditions ❑ Disapproved <br /> L (See ent With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN A9159R6INCE 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 OFT RK 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 WS OF CALIFORNIA:' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF 1HE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Co m FIA COUARY Date Vi/tO/20 1 V <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 `.-'OS£w '1 A CAG tY TITLE GeUj-T-*kr**- PHONE I:&PR, <br /> ADDRESS Z yi'70 vAA-6&IxD d.IRAc—f, 4 L. CDT. Cek `+S 74-0 <br /> SIGNATURE DATE <br /> -s <br /> EH230038(revised 02/20/09) <br /> 1 <br />