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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# <br /> A <br /> C Facility Name WI&1E COUM7K7 S'TA=T//o^' Phone# 209 - ,369- 36 33 <br /> 1L Address llll !c €T'rLEMA-" LA-Ne L52 <br /> ODI CA 940 <br /> 1,� <br /> I Cross Street S. /p CK M(1-N Ab <br /> T <br /> Y Owner/Operator �/� f'R�/ahb /t/bbY 7-A4A- Pi$ LLL Phone# pat,806 91 k g <br /> G Contractor Name R6 LI AZI-6F OF fie L&U M S eAV)U3, /At L Phone# 2.69- $W,Y- g S-g6 <br /> 0 <br /> N Contractor Address 51 1 13,0 Ait-JOIN6 /,P#A)V.,IDA"Wo CA Lie# v G Class R <br /> T <br /> R InsurerC EN( ,e�/If�GJtllA2 O,�,L^ a�tL� r� WOrkComp# <br /> A 'l <br /> T ICC Technician's Certification Number '5cj ' 1 Expiration Date -d° S I V <br /> Q ICC Installer's Certification Number 'jq�5&Sq C) � T Expiration Date q11 (0/(9010 <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> M <br /> �Q <br /> N Plan Reviewers Name _ Date_� _—_-- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO CE OF THE WORK FOR WHICH THIP PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." {`,, <br /> 4W <br /> Applicants Signature_ Title Date / <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. ((11 }� <br /> NAME SWDE �P S�ntGN _TITLE ��,/t.. "� __—_PHONE# 60$o6-91 %A _ <br /> ADDRESS I I F• kET7 LEAAAN L f1-N E�_ _LOa I CA_95 24 O __ <br /> SIGNATURE____ � -- <br /> EH230038(revised 12/31/07) <br /> 1 <br />