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01 0 <br /> 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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> AC Facility Name SawJouqui4,v planzEvu''� 'n�-=ac UtLe*M Phone# <br /> 209-915-2577 <br /> � Address 7000 MLcha.QLC 31yd4 FreAc;yCgjmp, CA <br /> TCross Street <br /> Y Owner/Operator Sa4,11joaquiev PLa4eLtEnqt:�Lng Phone# <br /> C Contractor Name 13ai��y�v�tevpr , Ivlc� <br /> 0 Phone# 209-367-4800 <br /> T Contractor Address 2370 Maq# o-CLr, Ste,4, Lodi, 95240 CA Lic# 774802 Class 8, E)21 D34 40 <br /> A Insurer StaVe C&MP I yWFU4,td Work Comp# 730-0000558 <br /> C ICC Technician's Name Expiration Date 7/25/2014 <br /> T je�Beru�tnet�Ja � on p <br /> RICC 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 AnNu Uw spaCPiwAwr 20,000 r0u'be� <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Dates d <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 <br /> TO WORKER'S COMPENSA LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> ,,__,_____,4 <br /> Applicant's Signa Title ate <br /> BILLING INFORMATION: el <br /> Cj <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAMET�IVB , (3113 .y EvltE42r4 % IME Ge izmbMaw .r PHONE# 209-367-4800 <br /> ADDRESS 2370 Mc"i4n,-Cir, Ste 4, Lodi,, CA 95240 <br /> SIGNATURE DATE /! f3fc3�®� <br /> EH230038(revised 07/22/10 <br /> 2 <br />