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Apr 12 13 08:59a <br />Mid Valley Consulting <br />0 <br />530-749-9892 <br />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 />p.2 <br />THIS PERMrT EXPIRES 160 DAYS FROM THE APPROVAL DATE- INDICATE PERMIT TYPE BELOW.. <br />G TANK RETROFIT D PIPING REPAIRIRETROFIT ❑ UDC REPAtRlRETROFIT D COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name , <br />Phone # r q – t73Y <br />L <br />Address <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator A L <br />Phone # _7zy 7 — q <br />Contractor Name L[ � (� <br />Phone # QyQL <br />T <br />Contractor Address �Li , - <br />CA t is # fid class <br />RInsurer <br />A <br />K <br />Work Comp # <br />T#CC <br />Technician's Name S <br />Expiration Date <br />� <br />' <br />ICC Installers Name � � <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 51 :eak deiedor, UDC VY. 0c) <br />ank Size <br />Chemicals Stared Currently <br />y <br />Date UST <br />Installed <br />T <br />d ' <br />i`1 cJC' <br />•'1 <br />A <br />0. <br />N <br />K <br />P <br />Approved _\-�pproviedwith conditions F1 Disapproved <br />L <br />A� <br />See achment With Conditions) <br />N <br />\ <br />Plan Reviewers Name / Date �� <br />APPLICANT MUST PERFORM ALL VVgRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER CR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME_ SUBJECT <br />TO WORKER'S COMPENSATI N LRW'S CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT iN THE PER FOR MANC RK FOR WHICH THIS PERMIT IS ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA,' <br />Applicant's Signatuje Tirle �f ! %f� Date <� <br />BILLING INFORMATION: j <br />indicate the respo to party to be billed for additional END staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. fr <br />NAMED. i fly' TITLE 1d' i 1♦ ! }L PHONE 7,/ `` G ri <br />ADDRESS: �? ft.y'LLf� %+ Ir "iJ�� i % r_ <br />i?✓� :t Ir C'Y/ �G <br />SIGNATURE; DATE <br />EH23003a <br />2 <br />Received T'ime__Apr, 12._2413_ 9:01AM No.28 <br />