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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# g,y„d y grojn <br /> � Facility Name 5e t%v Censer Phone# -?02 602 703 ' <br /> � Address 1010 W L51-cCXTili Ca. <br /> Cross Street Enter r;Se siree-r <br /> T <br /> Y Owner/Operator ?QC;: S t Electr:C Phone# .249 &OR 7038 <br /> OC Contractor Name &Pttler- 12,d4A Inc. Phone# /6 ew <br /> T Contractor Address674f? S;errr Court SW-le- 10.6h, CALic# ,gyp Cj Class /tt+q C.Aed <br /> R Insurer Stgi[ COM nS t:On F �At't4G work comp#000 ocal-.20io <br /> QICC Technician's Name Expiration Date <br /> T <br /> R I ICC Installer's Name n Mr. th W S Expiration Date / Z //(�/2c9/0 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T T — 0: I s :II 10uck f A9.0c,o 6" L), s �1nK�own <br /> A <br /> N <br /> K <br /> P ❑ Approved .R-Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date / <br /> /�I OV zS, d <br /> APPLICANT MUST PERFORM ALL V1000ORK 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 Tiae Sery:Ce. MAn43er Date 11 14 I0 <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 the billing by signature and date below. <br /> NAME Gei-tler -(Zyan Cnt' <br /> /MC• TITLE orC;CYc�/�� PHONE# 7 p <br /> .2SaS:I.S6C/ 7pS.SJ <br /> ADDRESS 67-/7 S errA Court SOIL *ft_ 7 Ovbl:n , G/ I <br /> SIGNATURE(:: 1!!� �nAtJ h IJ ri r.Jrf DATE jjj 2 q 1 D 5 <br /> EH230038(revised 02/20/09) <br /> 1 <br />