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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 /> %TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#X41 C.LI XR4 A j.To K 24 _3 1 -U s- <br /> A <br /> C Facility Name rL A C -r µ Phone# <br /> L Address 6 3} A-� Fit tj - L 0 D I, s i Y L- <br /> I T Cross Street <br /> Y Owner/Operator A(F..tnl v f 1S-r p a,-7-20 C Phone# q16 - �(q) - 9 k! o <br /> C Contractor Name p, (r'r�n( �.Q t �1-�^a 4 r_ Phone# y!6 3 - (( S"Z— <br /> T Contractor Address'B O X /p L r W, E A-c," 9 S h a t CA Lic# 6 ( 4-23t- Class 4,42- <br /> R ,4 Z <br /> A Insurer S-r p.�-pL j ,AA Work Comp# <br /> cICC Technician's Certification Number <br /> T S d/L Ar-l'T RA> Expiration Date <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T © 1 Z OIL S - A--5 a L� - <br /> N 7- <br /> K O 104 6/l. <br /> P ❑Approved VApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date s L <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 LA OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE O THE WORK FOR ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /+ <br /> Applicants Signature Title C&"R-fin— Date l 3 0 Fr <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 /> W <br /> responsibility <br /> for the billing by signature and date below. <br /> /Yl <br /> NAME l Cbl tel. A'(.I- ►` TITLE CG+17_2 At11-V( - PHONE# 01t(P 31 3 s Z <br /> ADDRESS A - l© Q 9 S 6 R <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />