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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 />C % <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT I UDREPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # A t C r'd A-tL A c j - <br />A <br />D <br />Facility Name (C2 U (jL S Tp #0 / S- Z- <br />Phone # <br />� <br />Address j S_ C'y. E41- 6 V_ q,� G ^.(_ G O b t Cy S' 2 yo <br />Cross Street AL inn 0 R - <br />T <br />Y <br />Owner/Operator v ((� Srt-p IO �� tyTr, <br />Phone # <br />o <br />Contractor Name W4 t, <br />Phone # 14 - 34-3 <br />T <br />Contractor Address $ X r p 2 r W - S A -v S6 `! <br />CA Lic # , 2 3 p Class A. B , 9 4 � <br />A <br />Insurer WT-*-- F,) <br />Work Comp # <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />I <br />10 k <br />ff� <br />A <br />N <br />,L <br />r 0 IL <br />P <br />K <br />P <br />❑Approved �pproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 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 TO <br />WORKER'S COMPENSATION LAM OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF HE WORK FO7WH CHTHIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />r-- / <br />it "� S Date (0 ® Y <br />Applicants Signature Title C 8+t;i �^ O <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. <br />NAME a I Gdl-_Ia (kA/Xj_ (� 0-( TITLE �B.rJCJ�f2 ,A—C7I""D R-- PHONE # I?" (P '3 (S—Z- <br />- 0 - 0 a)( . n i I— W- S A-vl� C A, A j—,6 It <br />EH230038 (revised 12/31/07) <br />1 <br />