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F% <br /> W <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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT A PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Cj,'r11S Blau&-' -4o-4-4&!5'—llcG <br /> � Facility Name AT a-T r-ac;1 VES Phone# <br /> � Address 345/J. Sa n Toa ;A St. S 6 C,4--6A C <br /> I cross Street <br /> Y Owner/Operator Fac4ic -f Zlf CJ6 krq- (J; Phone# 214 * 559( <br /> c Contractor Name 7D Phone# <br /> O <br /> N <br /> T Contractor Address CA Llc# Class <br /> R <br /> A Insurer Work CO # <br /> ICC Technician's Name Expigifikon Date <br /> R <br /> R ICC Installer's Name E iration Date <br /> Tank system work area Tank Size Chemica Stored Currently Date UST <br /> 0.e.87 Aping sump,B1 leak detwW,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (See chm nt With Conditions) <br /> A J Q <br /> N Plan Reviewers Name Date e-L- I 0 <br /> APPLICANT MUST PERFORM ALL WORK IN C R CE ITH SAN JOAQUIN VWNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEP T T.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS RMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNI CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMAN OF K FOR ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' p�/� <br /> Applicants Siynat a Tide I I 1 Date a <br /> BILLING INFORMATION: <br /> Indicate the responsible party to billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below ' different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing b ignature and date below. (�,� r ��j <br /> NAME al�S IPS TITLE ff 1 PHONE# �4`16 10 <br /> ADDRESS �? 9W. Iia C/[ 1 4 9A <br /> SIGNATURE DATE lo-7 -05 <br /> EH230038(revised 0212(109) <br /> 1 <br /> i ke 0.. <br />