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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 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT )(PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#ws}t 11 9373 <br /> A <br /> O Facility Name K Phone# <br /> L Address I (o Q-TU �- '� CA q5'9 30 <br /> T Cross Street p. <br /> i <br /> Y Owner/Opemtor C(/.G I 1 Phone# q51 '274) 51 44 <br /> Contactor Name Phone#O e- rpv es L qOj 923 9373 <br /> N Contractor Address 7O Syr_ ( j I . j��. I y A Lic# '77 Class-9 G10 04C H <br /> A Insurer `]}-u,� n� Work Comp# (o24 00013 1 <br /> T ICC Technician's Name ZNorna5 Benso Expiration Date30 _ 1 1 <br /> R ICC Installer's Name Tho Inn as Bcnsc)n Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (re.ar PINW yep.91 reek xiecror.UDC ln.et) Installed <br /> T Turbvnc 5imp VZ000 r <br /> A 91 i urbi ne. Sor4 I Woo 0 <br /> N <br /> K <br /> P U Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A /07 -0/0 N Plan Reviewers Name Date [ 07-0/0 <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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature Tire 7—e-Ghn.7 F6- Date IA I ,Q <br /> BILLING INFORMATION: <br /> Indicate the responsible 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 data below. <br /> NAME WS+in C+1IIE'M TITLE 69 e-� PHONE# 90y Q23 X137 <br /> ADDRESS 7470 SVL- (Sc+X Vic_1Dry r 11c- . CA 9 7-3 9.5 <br /> SIGNATURE !�j DATE 1i)1 14 /110 <br /> EH230038(revised 07/22/10) <br /> 2 <br />