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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 600 East Main Street, Stockton, California 95202 JAN 21 2011 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMIT/SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#44r, f w 1 ,91-U•6F-?b' <br /> A p _ <br /> G Facility Name Q1 1A S�-�S(� Phone# �0C1• y • 16� <br /> IAddress <br /> L ' i-rcef tocKton L 20 <br /> T Cross Street /_ 9 <br /> Y Owner/OperatorC.Scetr L.:S7Ar Phone# S30 6.2 077v <br /> o Contractor Name e tiler- G(1 r)r_ Phone# <br /> N Contractor Address CA Lic# Class <br /> T 6 14 S:err,. Cour t S4. 7 �?o X53 �4ttticti�d <br /> R Insurer <br /> A Ac(nr-d Work Com p#u=1'v 8° P ISl C <br /> TICC Technician's Name C rr'S �O(� Expiration Date <br /> RICC Installer's Name _ Expiration Date <br /> ,VIATank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T 87 S7P SSM vnl(nok. CO-- /1,0 own <br /> A <br /> N <br /> K <br /> P ❑ Approvedr.—Approved with conditions ❑ Disapproved <br /> L ( ttachment With Conditions) <br /> A <br /> N Plan Reviewers Nam 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: "1 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." f <br /> Applicant's Signat Title *tr- Date f 1 I I <br /> CJ/ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME Lnd!A Qrd)Lj ', TITLE Je-rV.Ce MQA4,nQr PHONE# 226' YZ- 7S rC� <br /> ADDRESS Q 7LI7 Coyr-t St!• i e 7 br✓k es , Cc{. '1A; 6 F <br /> SIGNATURE Z �� DATE T�c/�2011 <br /> EH230038(revised 07/22/10) <br /> 2 <br />