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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPEBELOW: <br />—TANK RFTROFIT ❑PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # it cµ 4" WA0i g H y, 6 -313 - it S - ,L-- <br />A <br />G <br />Facility Name Q �/ t (L S TO P / Z � <br />Phone # <br />L <br />Address 1 S- I& o W• W. A. t q S T-. j2 t P e+t . C A y S-3 6 6 <br />T <br />Cross Street S, A -C k Ir O I- V KZ -b - <br />Y <br />Owner/Operator Q J 1(L.. S -t-o P VIA b -IL 1G IL T -S y►Q C- <br />Phone # s 10 - 6 S4 S S'® o <br />C <br />Q <br />Contractor Name( " It, TO -L< '� C - <br />(Al(it/ A c �c we I�*Q <, . , <br />Phone # (6 - 3 4- 3 <br />NCAContractor <br />T <br />Address 6% K (o t r W- S A-t,,ro C A c(s- k ct 1 <br />Lic # Class <br />RA <br />Insurer � <br />Work Comp # <br />C <br />T <br />ICC Technician's Certification Number S E, t- A--rT qC*" <br />Expiration Date <br />QICC <br />R <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 />p 1 <br />64X- <br />A -SO tO-A— <br />U 1- t <br />A <br />0 14�- <br />_ Ott <br />tt <br />N <br />KS <br />- <br />❑Approved [?Approved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />11 <br />N <br />Plan Reviewers Name ���� NGti� Date 10 /0� <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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE Oy THE WORK FO0ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." ^� <br />Applicants Signature Title C O wC R. A -c 0 tL— Date E t t b <br />0ILL.11NU IIVry ivl/il IIJIV. <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 �sijg/nature and date below. <br />NAME p` V V A L' 1 014 TITLE 6^x_2 A— PHONE #�- <br />,m, BOIL ioZs <br />SIGNA <br />EH230038 (revised <br />1 <br />