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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Plain 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 <br /> DATE, INDICATE PERMIT TYPE <br /> I ryBELOW: <br /> TANK RETROFIT ❑PIPING REPAIRIRETROFIT iCJUDC REPAIRIRETROFIT A�JCOLD START/EVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone#At{IA" tal1,I'A'DR444 til&-5+l2-3GK <br /> C Facility Name CIR� K SsazE S INC. Phone# <br /> � <br /> Address I G L4-70 C/kKr3R.t'DGE Sf; 9S rz-0 <br /> I Cross Street L.OU 1 S AtV. <br /> T <br /> Y Owner/Operator CA ZCd tg, I<- SSoSLe_S I W(Z Phone# C-t 51 -270 <br /> D <br /> 0 Contractor Name I SL.PcI.JD [ iI-R.o L.�iJP"t Q�t vpEr cC,i I tJ G Phone# 0j0 y-Cj23-Cj r M <br /> N Contractor Address _]c.AZO S VL MaO_ V\C raC"ivtw CA Lic# '-1'i c Fr Aq 6 Class 13t C-IOC 0-40, <br /> A Insurer S-rprTr- C &V-. tP-I . F✓ND Work Comp# 4p.2•f-000131 "rc <br /> T ICC Technician's Certification Number 52 6$ Icl, _ LJ Expiration Date CZ 3o/20/ 1 <br /> R ICC Installer's Certification Number 525 -72 If-U I Expiration Date 2 /2. .2o I I <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 1 12 000 5-7 jzwo D K,a-.. ul-i k , <br /> N 2 1.2 00o 011 I-TZeta- Fruri ti Loi111 <br /> K <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 HEOTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FO HICH IS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF ALIFO IA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF TH ORK R WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." L/ q <br /> Applicants Signature_ Thle_ f Date_ • —I IL ____ <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 signature and date below. /,�• c t,�pJ <br /> NAME AC11I NI) G 1OAvr-r" TITLE_ ��C3i�N�+�_-____,,,_APH�ON�Ej#- �I6 4q2_-ZC r=l <br /> ADDRESS-2-01 1 W A" W' Sf'F-�p _m ormi rt-tL VT '✓L SO2 <br /> SIGNATURE <br /> EH230038(revised 12J IO <br /> 1 <br />