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liq <br />Fal <br />Mr.: • , ;17,4111imm . <br />SAN JOAQUIN COUNTY WI t'V E DD <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 UL 0 6 2008 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPIN& ° <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ERMIT/SERVICES <br />❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE" <br />F <br />EPA Site # <br />Project Contact & Telephone # (213) <br />A <br />C <br />r <br />Facility Name r 114t <br />Phone # <br />� <br />Address �S®% /�° �Gk, %bA � P6 A <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />o <br />Contractor Name �' e� r e <br />oiry►c s <br />Phone # c - 3 2 <br />3 i 3 -�'� c� <br />T <br />Contractor Address ' O S , �,�.�Ay Z <br />CALic# 3oZo c Class Cto.-Gtc•1 ONc <br />A <br />Insurer ,� Zt15� <br />. <br />Work Com # G <br />p Iw zgly3y8G5o/` <br />TICC <br />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 />( <br />jt <br />1 Z' QC e <br />J <br />eYl el Qc <br />A <br />N <br />K <br />4-3 <br />i2 000 <br />4 11 <br />Aewo <br />f� i! -P3e— <br />Stf <br />'j-01CV ® <br />0ie-,.<, L <br />P <br />❑Approved <br />❑Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT <br />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. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br />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 <br />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 <br />Title S" e r til iC Date <br />BILLING INFORMATION: <br />iJAZ <br />R-3 <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. ,tea <br />NAME 1� ` l� e ^L TITLE S t� - l S e Y PHONE # <br />ADDRESS d J ►ti-�.C� 4 �' '''t`� l l 2 1 <br />SIGNA <br />EH230038 (revised 12/31/07 <br />01 <br />