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Retie t�Sr-6L�� (1/23/(n Cg$ <br /> AJJed Ccv%6 r l nhrenabm 6114110 CSB <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Last 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'o PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F 1 EPA Sita# Project Contact&Telephone# f <br /> A <br /> Featly Name f-rq-T RdRy L) Picone# <br /> � <br /> Address SOS N. -%n 3� ffi 5E. <br /> T Croas Street La' SL, <br /> Y OwnsdOperator p2w4c W Wtfl16A C l'. 5 T97-Co A&-AIA Phane# ;.f4..464-�,RiLT <br /> a Contractor Name Oekt ler Ryaij Inc. Phone# $16-4,31-1300 <br /> RCGntractorAddress 1 4, ;,tc 504g--t CALIc# 6-f 13 Cl8ssC59 B(.(off 40 WAZ r4Lla <br /> A Insurer � 5 5d�,esn 1nSOWICe'Foyid Work comp#W030.58— <br /> T ICC TachniclaWs Name <br /> �� 8 f�� Expiration Date <br /> D <br /> R ICC Insiallers Name A"bvo Cr; UIIt Expiration Date <br /> Te system work area Tank Size Chemicals Stored CUrrenll Date UST <br /> (LeeJp�Yie�wpoll�cftww.U0014"1 y Installed <br /> T v i .ns ti 'e 1Y43 <br /> .ui —IT- V�►� rek�r I 25 Owes I " !`�93 <br /> K <br /> P ❑Approved ;9CApproved with conditions ❑ Disapproved <br /> L (See Atfachme With Conditions) <br /> A / !/ 7,. <br /> N Plan Reviewers Name ✓ Date Q r CMCJ 0 <br /> APPLIdIHR muffT PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCEB.STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY.RNIRONMENTAL HEALTH DWARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT lB ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUa.IECT <br /> TO WORKER'S COMPENSATION LAWS OF CALJFORNL4' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: h CERTIFY <br /> THAT INTHE PERFORMANCE OFTH@ OR WHICH THIS PERMIT IS ISSUED,t SHALL EMPLOY PER80NS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CJIIJFORPIVL' f� rn" <br /> Q M <br /> AVplicw"SkumIum J Mg. I + ' 1a ���Q <br /> BILLING INF=ORMATION: <br /> indlGate Ow responsible party to be billed for additional EHD staff time expanded beyond permit payment Coverage par tank. if <br /> the party designated below IS different than the permit applicant, e.g. property owner, the party rnust acknowledge thls <br /> responsibility Far the billing by s nature and date below. n <br /> NAME f 5 KC%L*% T C TrFLE. 1-I'n PHONE# <br /> AUOPESs 11 c �4,1� fe-tZ641 CA 01 9s <br /> 31GNATURE DATE <br /> E 30nfl(revised 02=09) <br /> .IAN 2 9 2010 <br /> SAN JOAQLHN COuNTv <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />