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12/24/2008 14:13 FAM 91631112540 BZMAINT X001 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Fast Main Street, Stockton, California 95242 <br />Telephone: (209) 46133420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />F <br />A <br />c <br />I <br />L <br />I <br />T <br />Y <br />c <br />0 <br />ra <br />T <br />R <br />A <br />G <br />T <br />C <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />THIS PERMIT 9XPIRES 180 GAYS FROM THE APPROVAL DATE. INDICATE PERM t' TYPE OELOW; <br />RETROFIT L. PIPING REPAIRrRETROFIT UDC REPAIRIRETROFIT DCOLD STARTIEVR UPGRAD: <br />--------------- <br />- Prosect Contact & Telephone # <br />EPA ;D40 # <br />Facility Name FC -0 NCS <br />Address IC-Top— <br />Cross <br />Cib12Cross Street RECt! il'14 N P-2- <br />Owner/Operator S V tLri Grt r T N S l N CIVI <br />Contractor Name ma"; _011A V-L't'^CP- - <br />Contractor Address 3 C H C, U S T n N 57 <br />ICC Technician's Certification Number <br />ICC installer's Certthcation Number <br />Tank IDN Tank S,x2 <br />Plan Reviewers <br />❑Approved <br />Phone#(209) -3�1q--V9" <br />Phone # t (q, 4 <br />Phone # <br />�CI class <br />Nark Comp # Z'L c-4 <br />Expiration Date <br />Expiration Date <br />Chemioair; Strad rete UST Installed <br />Currentlyh'reviou�ly <br />NAChTnent <br />proved with conditions <br />With Conditions) <br />UDisapproved <br />C� <br />F: SAN <br />,APPLICANT MUST PERFORM AL6 WORK IN ACCORDAMCE WITH SAN 10AflU1N C"TY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'UIN COUNTY ORDINANCES. GNATORE CERT F ES THE FOLLOWING: C! CERTIFY ULATIONSTHAT IN <br />THE PERFORMANCE OF 1HE WORK FOR MCH TEAS PERMIT IS !$SUED, I EIK4.l, NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />THAT N TFE PE COMPENSATION <br />LAWS p THEF GA R NhiICH THIS CTORTISI ZING OR1 SHALOEMPLONIR YIPERSON$ SUBJECT NG S*NATURE O WORE GRS COMPENSATION LKWS <br />OF CALIt'ORNIA." I I!, e F Z- / ©� - <br />Indicate the responsible party to be billed for additional EHD staff time axperided beyond permit payment coverage per tank. If <br />the party designated below is aifterent than the permit applicant, e.g, properly owner, the party must acknowledge this <br />responsibility for the billing by signature and cats below. <br />NAME TIT1..E PHONE # <br />ADDRESS <br />rt/ siGNATURE <br />'? EM23003t1 (revi8ed 12131/07) <br />O <br />