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'• ' <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 BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT 9 COLD START/ <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # K,w+,.� <br />G <br />Facility Name fCI S a( <br />Phone # am- �3s=Z�oB <br />� <br />Address 31�s i�v4e �V.J(Q, <br />TCross <br />Street <br />Y <br />Owner/Operator t�U?O�uCQS <br />Phone # lb7 VS <br />C <br />Contractor Name '-w—`fV Lt:.,e <br />Phone # <br />T <br />Contractor Address , $ Qu S's cA qwQ— <br />ICA Lic# 41K 4 Class Did <br />RInsurer <br />A <br />� W2� �1r.�UliCs�(�.{, � <br />Work Comp# 't�3IONL063&6Q I <br />cICC <br />T <br />Technicians Name <br />Technician's <br />Expiration Date 1:0 (L�. <br />QICC <br />R <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 Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <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, 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 CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />�,� , I (� <br />Applicant's Signatures ,: Title��Vi�jv�IlCl�(JLC�Q �T!'t(,�+CV Date if1Q[�-1 <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�1 for the billW <br />ling be ` <br />y �siggnature and date below. / �f <br />NAME M ay+,M • 4-L+U"IS A TITLE OLL4A6CU(u-C 6gtC*—PHONE # FV <br />ADDRESS l� 6 �UICA,�t}� SO-i.L J(`jSe (A <br />SIGNATURE DATE -i 1 t Ci l wo <br />EH230038 (revised 02/20/09) <br />KN <br />AZ <br />