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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 LOW: <br />,TANK RETROFIT 11 PIPING REPAIR/RETROFIT [I UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # ZZA7o <br />A <br />O <br />Facility NameS ���(� <br />Phone #a0 -1 .25 <br />Address16-W=7d 6#4480 9M LAA,6 <br />TCross <br />Street <br />Y <br />Owner/Operator 2XJ1Ad <br />Phone # <br />o <br />Contractor Name yVr&V*AkAfj4; '� L_ <br />Phone # 70-7 Ml _ giiV e <br />T <br />Contractor Address j4g,*jam, <br />CA Lic# �2 [ f Class � <br />AInsurer <br />�. G <br />Work Comp # d0�0 2 <br />T <br />ICC Technician's Name EV66g10," <br />Expiration Date <br />RICC <br />Installer's Name .45g <br />Expiration Date <br />Tank system work area Ta ze <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Chemicals Stored Currently Date UST <br />Installed <br />T <br />PQMIII(V r o 000 <br />^i <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(S A ent With Conditions) 9-$0-q <br />N <br />Plan Reviewers Name 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, ENVIRONM TAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSAT N LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMAN E OF THE WORK R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Sign re Title1(f{ii ✓� ate 0&i <br />BILLING INFORMATION: <br />Indicate the responsible party to b filled 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. e G <br />NAMEiQ(�LL?_i/�l TITLE�,�ilClFiPiPHONE #7D� <br />i <br />TE 2& "-' & II <br />