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0 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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE <br />I�BW. <br />IELO <br />f1 <br />❑TANK RETROFIT ®PIPING REPAIR/RETROFIT I Il1r)r RFPAIR/RETROFIT I I(:(ll n CTART/F\/R 11Pr_PAn= <br />F <br />EPA Site # <br />Project Contact & Telephone # 1 C 64 A. 916-3� -t <br />A <br />C <br />FacilityName CQAQCG PAItIL Pic � Z S y Phone # <br />L <br />Address wt E4z L N S 0 CC T" S 2( o <br />T <br />Cross Street &I T- <br />y <br />Y <br />Owner/Operator CO&COCO Pj41 L C L P S <br />Phone # <br />C <br />o <br />Contractor Name �- c.'i" Pt � � � � c r�ur�Z � � � � . <br />Phone # (:�t 4- 3 <br />T <br />Contractor Address g p X / p 2 1- (,!/ , S 9 S 6 9 <br />CA Lic # (47- 3& Class A, 6, <br />A <br />Insurer -t- p -T -t— Fu -x-� <br />Work Comp # <br />T <br />ICC Technician's Certification Number S &1�_ A -T --T k -C+ -k --b <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />0 <br />Z IL <br />t �S B2 <br />P <br />❑Approved pproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />j <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WO K 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 LAV4 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF HE WORK FOR WICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." Ot Id/^ / <br />Applicants Signature ` Title l 6 �'� CL I} -yl fit- Date S / (3 /® k - <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 <br />for the billing by signature and date below. <br />NAME Y VI 1 GW N-Wl _ �/UA'(���r( TITLE O -L -T-2 P -CP - PHONE # 9<6 - 3 4- 3 - 10S 1— <br />co z s-- l,U_ S <br />SIGNA <br />EH230038 (revised 12/31/07) <br />1 <br />r 2- <br />