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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# I Project Contact&Telephone# <br /> A <br /> C Facility Name qL n C i r l/Fz g et Phone#p2 0 q'- �/� <br /> � Address <br /> TCross Street <br /> Y Owner/Operator 20,G A L Phone# 901a— L//3-6-krO/ <br /> Q Contractor Name / <br /> 0 / /3 4 h 'n i%s Phone#0-3c 0- )yf ^q �9Z <br /> T ContradorAddress .0 97Z fjo,ed kj!L/dL I CALic# �t0 9 �J Class <br /> A Insurer Work Comp# a2 <br /> cICC Technician's Name 3 3'- /6 <br /> r l`t/1't LS Expiration Date <br /> RICC Installer's Name S Expiration Date /e2- <br /> Tank system work area Tank Size Chemicals Stored Curtenti Date UST <br /> Ito,B1 PIPng a P.91 mk Eetecxar.UDC 1n,no.) y Installed <br /> T C fQ jol-e i_ VIZ P II b <br /> A )ft4 30' n 30�IJts /rL <br /> K K} Atr/lyd., <br /> '( <br /> Z <br /> P ❑ Approved Approved with Conditions ❑ Disapproved <br /> L _ (See Attachment With Conditions) <br /> A - <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." p <br /> Applimnrs Signature Title Elio Date <br /> BILLING INFORMATION: <br /> Indicate the res i sible party to be billed for additional EHD 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. q �i <br /> NAME'A �Fkkn IPS O n'L TITLEy y�WA f 12— PHONE#`53 V2- <br /> ADDRESSO f! /8 fio n C0 /L l✓L µ.+t n S I L£ (q rJ'J^,G <br /> SIGNATUREJA�r= DATE 1/"/ 'F'01 <br /> _ y <br /> EH230038. 07122/10) <br /> 2 <br />