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0 011 <br /> ENVIRONMENTAL HEALTH DEPARW%NE1VE0" <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 APR 15 2015 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE P TYPE BELOW., <br /> 0 TANK RETROFIT u PIPING REPAIRIRETROFIT a UDC REPAIRIRETROFIT XCOLD STARTIEVIR UPGRADE <br /> F EPA Site# C ofie 006 d Project Contact&Telephone# Mofti[A Morl-m-r- -a6lj. <br /> A <br /> C Facility Name C-heve-or, 5FA—F-;Dn4 6ql(p-7 Phone# ZOq 18 -7419,3 <br /> Address 17-54 F-. Y0&,PPk1 4e, AVV,�j C1?5-5960' <br /> L <br /> T I Cross Street <br /> Y Owner/Operator Phone# 9 112. <br /> c Name Contractor NPhone# -71 <br /> N JL J3:*. <br /> 0 ftL Few <br /> T Contractor Address JO20 -CV"ntckw1AU4t Aid ICA Lic# 5C034S Class,4 *f2,&7,1 <br /> R <br /> A InsurerWINI 1Vt%Va11j0L C�Yffl&kt, Work Comp#664!E�Ijrg-2-7 <br /> c <br /> T ICC Technician's Name Expiration Date J(). I(e.116 <br /> 0 <br /> R ICC 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 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P <br /> J Approved XApproved with conditions 1.1 Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name-LLO&O, Date <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 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PEFOR CE OF THE WO OR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ' <br /> L <br /> U,f U.0 <br /> Applicant's Signatur Title Lrolet f Maplfr:2�—D.t. 1-3-16 <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 /> NAMEMOKiCrt MOUVWK TITLE Proj.�C &f A*AltklqPHONE 11 <br /> V <br /> BlkV( Sk L900 YZA C4j q <br /> ADDRESS 14"EA' 5 - <br /> SIGNATLIR��- ,,-�Cst-, DATE 3 As- <br /> EH230038(revised 07-17-2014) <br /> 2 <br />