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ENVIRONMENTAL HEALTH DEPARTFff�V <br />SAN JOAQUIN COUNTY SEP 2 u 2004 <br />600 East Main Street, Stockton, California 9,5202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIROWENT HEALTH <br />PERMMSERVICES <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 <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name OM D <br />0! <br />Phone # 2(fj A S-2- ZZ( 3 <br />� <br />Address 00 8 % ,0j7� <br />/c 6U GI(I%i2 0' 957. %U <br />TCross <br />Street <br />Y <br />Owner/Operator Gfv,�I✓lln <br />Phone # <br />CContractor <br />Name /� ��0� <br />Phone # <br />T <br />Contractor Address///U k/ /��L/ <br />y 37 Gr�aU <br />CA Lic # -7(-/3/4,,0 Class <br />AInsure <br />rt /� �( Ak <br />Work Comp # <br />T <br />ICC Technician'sName o v Ad un <br />0 C7Z3 S (f- L4 -r <br />Expiration Date 1 ~ I'I - ZO 1 <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />87 91 leak detector, UDC 1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. piping sump, etc.) <br />T <br />A <br />N <br />K <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 1 �y <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I 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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />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 />Applicant's Signature <br />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 />NAME <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />ONE # <br />