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L <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 But Main Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAI ERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> 13 TANK RETROFIT IO PIPING REPAIRIRETROFIT C1 UDC REPAIRIRETROFIT 11 COLD START R UPGRADE <br /> F EPA Site# Project Contact&Telephone# j _JEW450v, (14)47--2400 <br /> A <br /> Fadity Nance bT'tT Fact ji I,) Phan# <br /> L Address 345 0. S n U di SE. <br /> I Cross street Lor 5L. <br /> Y OwnedOperator Pa,4e {CQ c Co. 14a +T*7-CA&Y-A!A I Phone#/;x 464=55`j <br /> o ContraCtar Name 'r'gD I Pho4# <br /> N ConVactor Address CA Llc# Class <br /> T <br /> A Insurer ork Comp# <br /> o <br /> T ICC TedWdan's Name Expiration Date <br /> R ICC Installers Name Expiration Date <br /> Tank systern work area Tank Size /erricals Stored Currently Date UST <br /> 06AW o"W WAM et ho a.uaa,we+n.re.] Installed <br /> P4)<ro, I Y43 <br /> �rf`� 3*A b fGW ird <br /> K <br /> P ❑ Approved with coqd1jilions. ❑ Disapproved <br /> L (Se Atta sI <br /> A V/ C - l©, Z007 T- <br /> N Plan Reviewers Name Date <br /> APPUGINT MUST PERFORM AL1,wORK IN CE WI JOEAQI![N C NANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> Jpy4M COUNTY,ENVIRONMENTAL HEAL AR OR LICENSFA T5 SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT SJ <br /> THE PERFORMANCE OF THE WORK FOR I THIS PERMIT ilk ISSUED.I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SLiBJECT <br /> TO MIORKER S COMPENSATION LAWS OF OMOA CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTiFEE3 THE F[x LOWING: '!C6RTiFY <br /> THAT IN THE PERFORMANCE OF THE OR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFOMW <br /> 8lptplurs � Tine PM Data <br /> BILLING INFORMATION: <br /> Indicate the responsible to be biped for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> Me party designated ie different than dw permit applicant, e.g. property owner, the party must acknowledge this <br /> responWAlky for the bit g by nature and date below. <br /> NAME ` TITLE Pill PHONE 0 '10- 1-43-IC40 <br /> ZSR7E <br /> S � DATE ✓!a ��"C7`i; <br /> 8*30038 wed a¢12=9f 10 <br />