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• 0 <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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # ^ J <br />A <br />D <br />Facility NameAr-cc s o Phone# 209. 1-1bIbl <br />� <br />Address i6� W. -r Street 51%DC.K O C4 54-20 <br />TCross <br />Street <br />Y <br />Owner/Operator 91P-Ar.SCO tt" L. tc <br />Phone # r330_ 62 / _ O-7-7 0 <br />C <br />Contractor Name e --r fi I e r- p-jcIn In c. <br />Phone # °Iz.S- SS <br />T <br />Contractor Address 7y S:err-.q �Vr : to 3 <br />CA Lic # 2 2 ©'7 3 Class/4 -� CAe <br />A <br />Insurer ccn r <br />Work Comp #P-r7V9Z9'27PL1J,5I0 <br />T <br />ICC Technician's Name Ci�r`:Sto her : Sk c <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />S <br />80 c S <br />n <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name //�� /(/ -- Date l <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 T WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signatu Title V' Ce PIC4jon n Q r Date 1(0 - 2S - 2c 10 <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 for the billing by signature and date below. n <br />NAME nc1`� �('dl./tTITLE SCR%.(n �J�GSQ-r✓ PHONE # 9 ?A 66"2J <br />ADDRESS G7w-7 S. erre Cgcyr-4 SLY:ie- S, dvb I.'l Ccs. 91-IS6P <br />SIGNATOR DATE I D ZS / U <br />EH230038 (revised 02/20/09) <br />