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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />COPY 0 P Y <br />Telephone: (209) 468-3420 Fax: (209) 46&3433 LIU <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 EIPIPINr REPAIR/RETROFIT ❑DOC RFPAIR/RFTR T IInm n sreernam �,or_oeno <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Scnl i CoJ 6'9 - q S t • SZZ • S11 O <br />D <br />�/ <br />Facility Name l 1Z G FEZ s % 614 1 <br />Phone # 7-<>q y; -S 30 % <br />Address 1535 6• PES GA <br />T <br />Cross Street M A c p a,•r l+ u Q <br />Y <br />Owner/Operator tZlaw A Tc.D SMt fii <br />Phone# Zo9-$s3 130,0 8 L <br />C <br />Contractor Name C C. fL• <br />Phone # 1#2 j1- bZ --'9 (le <br />N <br />Contractor Address Se44&1 b 2y G R E6 L eZ1�E l o Lj <br />CA lic # p 3 Iv J �O Class <br />RInsurer <br />A <br />i'FS IrJSu2dAGE <br />WorkComp#HOZ I <br />D <br />T <br />ICC Technician's Certification Number 5Zsrf 73 to <br />Expiration Date 1 1 r• t 7- l g <br />o <br />R <br />ICC Installer's Certification Number S Z S 44 -T'C 6 <br />Expiration Date I 1 /r (, / P00 <br />rl <br />Tank ID A{/p1 9'S l <br />Tank Size <br />Chemicals Stored <br />Currentiy/Previously <br />Date UST Installed <br />T <br />^AnZy 9SO 6eAa01L <br />6toop <br />&GA& <br />990 <br />A <br />N <br />j Asopp <br />t0r00-0 <br />SoF�P io�t.�L <br />lZ�l 199 <br />K <br />MrW11 ._2017 <br />P <br />❑Approved NApproved with conditions HDisapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name t Date ✓r 2 0 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY. ENVIR NM TAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN <br />THE PERFORMANCE OF K OR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATI F CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br />THAT IN THE PERFORMAN H WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CAUFORNW <br />Applicants Signature _ Title P:'.W . "A A16664— Date 7—.12. 14 <br />BILLING INFORMATION: <br />Indicate the responsible parry L 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 the billing by signature and date below. <br />0fL; R-0 , STE A• 4SL , M6dt <br />SIGNA <br />EHZ30M (revised 17131/07) <br /># GSt- SZZ—S"Itp <br />