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• ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />r� <br />L <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 [9 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />a®V '9-5-1-'7708 <br />� <br />Facility Name .4• &-p_7b S $f <br />Phone# �ao �� �„5'/ - 17 7® 8 <br />I <br />Address �(� �� /� f l�1 y j m 6A, /—A Al Z <br />T <br />Cross Street ,¢ ,P K wo 0-D <br />Y <br />Owner/Operator f / g ; y r c,�/ 0,;L Co 'r P <br />Phone # Oe �� y �°� --2 5wo <br />o <br />Contractor Name S'tiVi� GOn/S;.e,JG iiv�/ /�/� <br />Phone# t;S3r <br />NCA <br />T <br />Address 11q01 .S ,9,1- A C O UR i <br />CA Lic # <br />7 >�$ b' 9 Class A <br />A <br />Insurerp,Q j �t ,e,t/ /n�S, rR/},tr� e e::�fo pF A/, Av o R,, <br />Work Comp #,e— 030 6 J 0606 00 <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently Date UST <br />Installed <br />T <br />b <br />, Da'D <br />1/4. A A, <br />LN G e A -2 �. <br />A <br />(/ j d� <br />�� A�/(f i'i <br />�s✓Lf� f}1D <br />N <br />K <br />,pilo <br />Jis t St L <br />P <br />❑ ApprovedApproved with conditions <br />❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />&Zc�5 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS <br />SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature (.� \ Title /M1 <br />Date <br />BILLING I FO ATION: <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 f r the billing by signature and date below. .� <br />_ �np- <br />NAME r✓I % I PA L l aV A qA TITLE E A s U /2,t:.. K PHONE <br />• ADDRESS / � �� /�V - /�I n//YI " /— .�/ s / D G K <br />EH230038 (revised 02/20/09) <br />a� <br />r <br />E' <br />