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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />C&ANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />Facility Name SC14Phone <br /># aO,. $— :S�-o <br />� <br />Address i $()V&j S+.. �YC')�CA <br />I <br />T <br />Cross Street C -t V V0 t vols-u.011�1. <br />Y <br />Owner/Operator SO— TYI�,. S�tl <br />Phone # �.,.. 94S0 <br />oContractor <br />Name�j��W—S'&t(,Ot4 S S�jA�I.'9 ±bNC <br />Phone # 68 — a (a . (00 3 7 <br />0 <br />• <br />N <br />T <br />Contractor Address L0 8 V RV2. �'�Ir�. <br />CA Lic # 6 if Class $� CIDI IDD <br />R <br />A <br />Insurer , `-� ,,.. _n <br />i1�SR�V�lt3� I V:P— <br />Work Comp # <br />T <br />ICC Technician's Certification Number Sa b 1 I a — VT <br />Expiration Date (e f 7,W'% <br />Q <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />- &4ytU OLA <br />i <br />A <br />N <br />K <br />P <br />[]Approved pproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />, AI n� d <br />J' 61 �� �+ <br />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 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 TO <br />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" 1, (� i r�'',/ry/ 7 <br />V �-y� Title \C L&XC. + Date q - Z' ` <br />Applicants Signature <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 HAR 1 tW V WZ 1"14 TITLE QV1kP1L6LU- C 64"PHONE # <br />ADDRESS (0%() k%)"" /Cl1"� �1Q �L Vi�� [ CA 1511 a-- <br />SIGNATURE yj rj,w�J V ' <br />EH230038 (revised 8/8/06) <br />1 <br />AZ <br />