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0 0 <br /> 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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name SAj :=Ara %sJ 41"E67eWALPhone# (coq) 493 —3728 <br /> I Address -1533 £_ i—M0155 wy SY2 E Er 5'RxKTO.� GA �J 520 s <br /> L <br /> I Cross Street Lir 0.2 w*Y <br /> T Phone 4qA - 3728 <br /> Y Owner/Operator $ 7'R� — D044 scAW 1'11 ��� <br /> c Contractor Name GA&"Y Y VjMTt libkwS£S WWd. Phone#(20q)3to7— 4900 <br /> N Contractor AddressZ$10 MP6LL77CSRs1.£ tl4 lOtit" Cpq$ CALic# 'i74$02 class(;,D21,3440 <br /> T <br /> R InsurerMOwbC �MDN0.0IE =E C&AP 2v$, F4f)D Work Comp# 1933126 <br /> A <br /> T ICC Technician's Name _)Of QARZ1104D r '1d'494'a 04rs 6 4L Expiration Date -71-1/1-1 <br /> 0 <br /> 71 1- <br /> a ICC Installer's Name 5Di $+1Arn igi 4 43 410 fi 642 Expiration Date 7/11/13 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 1187 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> It DC 1 O'J1. 2- OT£SfL F=u£L <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (See Attachme With Conditions) <br /> N Plan-Reviewers Name Jv, Date <br /> APPLICANT MUST PERFORM ALL W RK INA O ANCE WIT SAN JOAQUIN CO TY INANCES, STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEA DEPARTMENT.OWNER OR LICENSED AGENTS 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 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 Signa � { Tflle �s"19aM MA'►+fi6F.R Det- O 12 <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 tthhe�billing bnature and date below. <br /> or <br /> NAM %ACs"y F SS• 3�C TITLE QOIVAfi�- M � PHONE# 0,69) 3'7-4�� <br /> E <br /> ADDRESS 2370 MA'6C= Com, 4d-Lilt, t_�a= �' 457-4u <br /> SIGNATURE DATE D 1 02. Z <br /> EH230038 <br /> in <br /> 08/1111) 01 <br /> 2 <br />