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ENVIRONMATAL 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 TYPEBELOW: <br />❑TANK RETROFIT []PIPING REPAIR/RETROFIT ❑tint RFPAIR/REO <br />TRFfI <br />IT I (,.r)t n RTART/F\/R I IP(-PAnF <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name �/Ck�,�V�cy <br />�o, IL <br />Phone # Z<� `� 5W FVIL <br />� <br />Address <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator �'.� �� t rt ��; u ,,� <br />Phone # 20 7?'3 F 7 <br />oContractor <br />Name I/o.,,, -1,-j (!�C 4r c" <br />Phone # <br />T <br />� <br />Contractor Address O, n� �4, rel <br />CA Lic # Class A-13 Aa.,- <br />-� Ip 3 <br />AInsurer <br />S In (-_,,� `133�� <br />Work Comp # O �✓�- rad c 60?& �g <br />C <br />T <br />ICC Technician's Certification Number 5 -Zs -003 2- - txT <br />Expiration Date &/,(,r jQ� <br />R <br />ICC Installer's Certification Number 2 5~O03 -Z _ U 2 <br />Expiration Date /L /y �v � <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <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 <br />1011 <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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title Date <br />bILLINU INrUKMA I IUN: <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. <br />NAME Vta I �y PcC(��Z �� ���`���'^ TITLE PHONE # <br />ADDRESS �� �f!f� e I� ���C' K <br />SIGNA <br />EH230038 (revised x'2/31/07) <br />1 <br />