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0 <br />• <br />ENVIRONMENTAL HEALTH DEPART `oI��1-- <br />�,��� D <br />SAN JOAQUIN COUNTY L G , l� � <br />600 East Main Street, Stockton, California 95202 JUN 1 9 2-008 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />EN`JlROM9EN1 HEALTH <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING I(JR IT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ K RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT XCOLD START/EVR UPGRADE <br />Hppocancs aiynaw <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. � t� <br />NAME �jDA2 (1i2rt'-D (4f �5brN* ) TITLE ` rbl- ' jr• PHONE <br />ADDRESS 037 Iv 0620t -r -ll S1Vd p�Zl urMZ , 6A 611 154- ��1�3 4►17(li/Sp/D t f,t 6 -6Dm <br />SIGNA <br />EH230038 (revised 12731/07) <br />1 <br />TAN <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name5 e,11 # l b&l987 : &r2n'i Lime: 5hGj1 <br />Phone # • b3(p� 5��� <br />I <br />Address 2375 W - 6"^"t Lina IZA. , T>'Fe <br />L <br />I <br />Cross Street j0,112011-64, Pie --YT <br />Y <br />Owner/Operator 5he-jt Oil Orti�'s L15 <br />Phone # jip -$i(4, ..Z?-�4 <br />c <br />Contractor Name %able, 11zivi%etiar►ez (attn. t12 Phone # 40g -7_j?)-6538 <br />N <br />T <br />Contractor Address jZZ4 fon-a1 I�kw stip 1?062 CALic# 31ZB44 Class Al 4' Glv' <br />RWork <br />A <br />Insurer ReAwoo I Fire & 695u%HY Ins, Co. <br />Comp # Iii M 3C� <br />So5 <br />T <br />ICC Technician's Certification Number 5? -54-757 - UT <br />Expiration Date <br />QICC <br />R <br />Installer's Certification Number 5252032- U 1 b 5250!.10- U i <br />Expiration Date <br />/Eit2nki -Voreg„-a"^ - iit> <br />l Tank ID # 0n2rgG <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />1 (700 <br />iZ.000 <br />�,6nkzd� <br />aZ <br />(�qa) <br />12•000 <br />L1�lc�d <br />K,5 <br />(loq� <br />1Z,OlJO <br />Uv+l�adul <br />it') foQ7� <br />12,4,06 <br />I>ie�tj <br />P <br />❑Aper ed pproved with conditions []Disapproved <br />L <br />(S Attachment With Conditions) f <br />/ /( <br />N <br />Plan Reviewers Name Date 2� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />JOAQUIN COUNTY, ENVIRONMENTAL <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 />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S <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 />L I�,4 .,C Able flak. TNia Prt> i . t4A r. Date 67/0 <br />Hppocancs aiynaw <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. � t� <br />NAME �jDA2 (1i2rt'-D (4f �5brN* ) TITLE ` rbl- ' jr• PHONE <br />ADDRESS 037 Iv 0620t -r -ll S1Vd p�Zl urMZ , 6A 611 154- ��1�3 4►17(li/Sp/D t f,t 6 -6Dm <br />SIGNA <br />EH230038 (revised 12731/07) <br />1 <br />