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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 BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT 9 G91=8 STAR;/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />Facility Name 5hcll 13ColaCv -TP2G5he11 & Mini 1'13x'1' <br />Phone # 20q- 835- 7&'* <br />� <br />Address ?)7Z,5 Z ,5 -r�= $lvG! , Tr24y <br />I <br />T <br />Cross Street 1-2.05 (an raw.P) <br />Y <br />Owner/Operator 5\41 Oil F1-00VC*5 <br />Phone # 31D- lot&- ZZ071 <br />CContractor <br />0 <br />Name A61e- t 1a„ntenanee. �l'n:l�� W6Wr. �2n <br />Phone #.Cl�- Z13 - Cod38 <br />T <br />Contractor Address 3Z2,q• icnal pk„� , smhs Iia <br />CA Lic # 3 � Zf5+4 Class ' 1& 410.4lu <br />A <br />Insurer 1n5ur2ntt (,&M 2n of th-e- We <br />Work Comp # 1111Pt.50on4;03o0 <br />T <br />ICC Technician's Name 5254757- LIT <br />Expiration Date <br />o <br />R <br />ICC Installer's Name D U I Z 5?- 10 - U I <br />5252 3z - 50� <br />Expiration Date <br />p' <br />(E,) b Mw0f arik system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br /># 1 ( 7063 <br />IZIWD <br />Unlru&A <br />T <br />N <br />It Z (704) <br />(Z,Ovo <br />Uiolc24td <br />K <br />710 <br />12,000 <br />Un(eztk4 <br />#� (711) <br />0; e. <br />P <br />❑ ApproVE J Approved with conditions ❑ Disapproved <br />L(Se <br />A <br />N <br />Attachment With Conditions) <br />3 i � bel <br />Name Date <br />Plan Reviewers <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN QUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 />Applicant's Signatu40'2Title C. Date 3 5 <br />VV_ 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 />NAME z1y� c�iaYllv,,b t tG� TITLE 17C J. nt- PHONE # 707 -165- 1&46 4ef IN <br />p ADDRESS 1137 N- MONO `3614 • 1' 11UInna 6A 'K154 atha►1 t Za19Z.g11n1✓1D aS tG.GUYVi <br />a V <br />SIGNATURE DATE <br />Q EH230038 (resed /09) <br />1 <br />