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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 DAYSFROMTHE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT 11PING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # R,� A-,jr dCia t4) S( D- ti2,)0 <br />A <br />D <br />Facility Name gUa qrn y,� <br />Phone # J 4loto _ �019��3 <br />I <br />L <br />Address tzo S. k,A3 %—SpvT's C�UT&4 (1 C, <br />TCross <br />Street <br />Y <br />Owner/Operator WdI%kT EaiLYLPQ� �� -11A 2 LUC <br />Phone# LtLs`. (p(,2 -z <br />oContractor <br />Name '0, t <br />Phone # <br />T <br />Contractor Address 11746 TvIAV to os,, <br />CA Lic # '5416 Class to A L ( � <br />R <br />Insurer YL4vdl.�^Q GA T� Jk <br />Work Comp # pAW.,f -1605 ('li6,So(o <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />RICC <br />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 />�LUvo <br />Ua <br />A <br />12, 009 <br />Xyw)ff <br />N <br />K <br />P <br />[]Approved ❑Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <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 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature_ G-1 u ` l� Title MNN-PJ A 4iCYL Date � / ^ / Z o r/ <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 L-` LC,, %.* -r TITLE V1AAr-3 r4f,,,e PHONE < 2-0''k) 9 (% -7$ 2 S_ <br />ADDRESS [:W S, LZ 0.SorJ 1-13 /N—t' S Tt.,uc i v—L GA 1092.os <br />SIGNATURE ftp++ -a- -- `d:. lI-- <br />EH230038 (revised 8/8/06) <br />