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r • A , r ♦ �. <br />600 East Main Street, Stockton, California 95202 MAY 2 12009 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />ENVIRONMENT HEALTH <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR FRMOMOAR 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 <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name " l_ ( ( <br />- <br />Phone #apq �630_ G <br />Address o� ia(7kjo 90 <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name <br />Phone Phone #�,q . 3 (05 <br />T <br />Contractor Address 111)V2. VegeLfth,LtlLqy4 CK{ Q gv{p <br />CA Lic # —14 b I(OL) Class <br />RInsure <br />A <br />eak-�57,q.L <br />Work Comp # 3 q7i 3 (l0 -7 <br />cICC <br />T <br />Technicians Name <br />' s 601 !04-I - (.('t <br />Expiration Date `p—&— Zo/D <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />0 a 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved �� Approved with conditions Disapproved <br />L <br />A <br />(See Attachment With Conditions) <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 <br />TO 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 />Applicant's Signature Title Date <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 />SIGNATURE <br />EH230038 (revised 02/20/09) <br />TITLE PHONE # <br />1 <br />