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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 )4 PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# A 13eMW_V• (I i'&)9-4 2,,4400 <br /> A <br /> Facility Name �4T4~T ac i Ii Phone# <br /> � Address 3M5 0. S6n 3W2t OLA :SL. <br /> FCrass Street L,,, 5 SI:.. <br /> Y Owner/Operator pac;d1C C. CO, C.�& ArTVr C 1&rAIA Phone# - 4(A - j <br /> c Contractor Name '�p Phone <br /> 0 <br /> N Contractor Address CA Lic# Z Class <br /> T <br /> AInsurer ork Comp# <br /> T <br /> r ICC Technician's Name Expiration Date <br /> o <br /> R ICC Installers Name Expiration Date "q1P <br /> Tank system work area Tank Size /emicals Stored Currently Date US <br /> p.s.97 piping sump,41 leak detscW,UDC M4 ele.) Installed <br /> T sv 1 f CM <br /> �n soon y �e <br /> A <br /> N <br /> K �to <br /> r <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L /eettachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WOVACCORDWITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULESAND REGULATIONS OF SAN <br /> JOAQUIN COUNTY.ENVIRONMENTALENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FRMIT i5 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWSCONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' p <br /> App 3 Soh-- Title ! Date !1 <br /> d-o _I5 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to/ebilled for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below i different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by nature and date below. p <br /> NAft+lt &- TITLE Ptr) .PHONE# <br /> ADDRESS !��� 1J• t4 C-D re_uiuv-a CA 014154- <br /> SIGNATURE DATE jQ 0�`bg <br /> EH230038(revised 02!20!09) <br /> -�t t C o�� <br />