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0 & <br />From: 6616349233 Page: 414 Date: 2/24/2009 8:54:19 AM <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3.420 Fax: (209) 4684433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMfr <br />THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFiT ❑ UDC REPAIRIRETROFIT COLD STARTlEVR UPGRADE <br />P EPA Site # Project Contact & Telephone # ryt . l <br />A r`�Xr57Uprr�shi' '�- I ^ � <br />C FaClTily Name (t 5 1P11�hone # � .- 67 , <br />Address ' l w• �., e*i' W a L �, 1 <br />i cross street <br />r <br />Y Owned0perator VW t4 fakKc e.t Phone # ryQGj- - , ,91 2-- <br />o Contractor Name 5.1 c,. Phone # r� <br />T Contractor Address (7d Y CA Lie # <br />R Class <br />A Insurer );40 Work Comp # co Gtr <br />T ICC Technician's Name <br />o rA-f" ftir$Wn Date <br />R [CC Intakes Name r �1 vr, r , • �S Z�tJu �~ <br />Expiration Date <br />Tank system work areal K <br />P.O. p <br />T� Size Chemicals Stored Currently Date UST <br />sr iphlr erp� w Itgk deuoc 1!4 x <br />cor,0m)Metalled <br />T, <br />A <br />N <br />K <br />L Approvedpproved with conditions © Disapproved + <br />A (^"' a Attachment With Conditions) <br />N Plan Reviewers Name �-- Date t C 0 <br />i <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE$, STATE LAWS, AND RULES AND RMOULATiONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH 099ARTMENT. OWNER OR LICENSED AOITB SIGNATURE CERTIRIES THE FOLLOWING: 'I CERTIFY THAT IN <br />THE PERFORMANCE OF TI* WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMRI.OY ANY PERSON IN }{ A MANNER AS TO BECOME SUBJECT <br />TO WORKERS COMPENSATION LAWS OF K FOR WHICH <br />THIS PERMIT 16 HIRING OR SUWONTRACMG 31"TURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.*L( <br />Indicat® 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.9. property owner, the party must acknowledge this <br />responsibility ffbrr the <br />/billing by signature and date below. �i <br />NAME //!i/�G �IGJOh TrTI E e. PHONE # ( zz' <br />ADDRESS 1 Fio--+4 i�� t.J�.f-}' _C rYrk , S'��,��.-, C Z c �... <br />SIGNATU nATS 7 AY/a 9 _ <br />EM230038 (revised 02!20109) <br />1 <br />This fax was received by GFI FAXmaker fax server. For more information, visit: http:fAvww.gfi.com <br />