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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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# A "i ' <br /> A N Bt�k 1 uA qx3 0845 <br /> Facility Name Phone# r <br /> I <br /> L Address AtILP 1E" Mk2CA —,fL10 <br /> TCross Street <br /> Y Owner/Operator OA I I 1 C" Phone#rjlO�3�'�BGQ <br /> C Contractor Name �k,�� t� ��r 1 .. Phone# ,gyp .sim <br /> TContractor Address ,(�L ' CA Lic# Class I <br /> R <br /> Insurer C0" Work Comp#-�uOL�Xjcrv6q <br /> T ICC Technician's Name LA W11..Ld A,MS Expiration Date <br /> D <br /> R ICC Installer's Name �� S Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> l,e.87 piping sum`p,91 leak detector,UDC 12,etc.) n Installed <br /> T 1A ` 0 t� 3 1-2wU Q <br /> N 2 I PeEMIOM U L 3 <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A achment With Conditions) <br /> A q <br /> N Plan Reviewers Name Date T-�bl �2 <br /> i <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 AGENT'S 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 ORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's SignatureLit. Title f4vP'1 t 7 TECH Date // ' 7012009 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for <br /> the billing by <br /> signature and date below. Q <br /> NAME 1- 1P`4'`-t� CJIA'�VA-4�L.LI C� TITLE 0o'I IGpGI�'� PHONE# �4 -U � C.�/�7 <br /> ADDRESS P 0 • lk&o, ( LcLd-+ Q 1 XO'1--I-t C^ / .S(D2O <br /> SIGNATURE , DATE <br /> EH230038(revi 0 /20/09) <br /> 1 <br />