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i r <br /> 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 REPAIIR RETROFIT $ COLD START/'EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name W/ME C.mUNI %j SjPr7l6N Phone# 09- 365-3633 <br /> Address f\ 1 1 rC IF—i T LEIS fFN lAMe CIS Q T2 U 0 <br /> I Cross Street <br /> T Phone Ufj$'� $QQ-,glLt <br /> Y Owner/Operator spril'D EE P S I N C h �i <br /> G Contractor Name L'C I TE Co N T AA-C700Si I N C Phone# 2�9 — 4 6 1 ^ 6 33 <br /> 0 <br /> N Contractor Address 2$ 3S (014W1VA 'DI? QT6(k7ZM CALic# ' QQ 6 Class -10 HAS <br /> T <br /> R <br /> Insurer 'L'CtN�. C ` C2 Work Comp# LLMC 09 till-(.W <br /> T ICC Technician's Name L Expiration Date QED <br /> o ICC Installer's Name J4 I� Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.e]piping sump.91 leak detector,UDC la,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMP ENSA ION LAWS OF CALIF IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN OF THE WORK FO ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." qy ) <br /> Applicant's Signature__ — ___Title_—_1J_`^'��y`_—Date__ — <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 <br /> r�and date below. ��r���yJrr�� �r , I Q ^ l{ <br /> NAME_c Pr-M%G" �II lV�y-1 TITLE��AJ't'G „_/� /_� PHOQNEr# `'r b -�6 <br /> ADDRESS 1\1\ C'::t!:t —��1 , C.l l1.1L 14 0SIGNATURE --DATEEH230038(revised 02/20/09) <br /> 1 <br />