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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 /> D Facility Name- 1 ,cc 02 I ft c. Phone# <br /> IAddress <br /> L �1Ce;�1� tct t <br /> TCross Street n ,`ry-a- <br /> Y Owner/Operator Phone# <br /> 0 <br /> Contractor Name s Phone# (�{ ?� JZ <br /> N Contractor Address �(� ` �C j� � l , ' -� CA Lic# 3( ?jL41S Class -Z G(y <br /> T <br /> A Insurer Work Comp#BIDIJ- <br /> IC �i/ D110 <br /> T ICC Technician's Name Expiration Date Z 21 Z � <br /> � <br /> r <br /> R ICC Installer's Name Doi) b C-L� bcs <br /> Expiration Date cj �2 <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 /> A - V Ch v (�l3G►��4 <br /> K C VIS g <br /> P ❑ Approved approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> v� <br /> APPLICANT MUST PERFORM ALL W 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 PERFORKAAN F THE WORK FOR W THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> \ i <br /> Applicant's Signatur Title Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party Q_e bi'lled for dditional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is differe than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. ( t� ��� <br /> NAMEAIV! ` 400INCA `�°�.:fIIVE QDC�HCl k�%(�!PHONE# 4 I� O/-- 0 <br /> ADDRESS 1 �Ml3r 71A3eGi�1 i� t � t VV aG Rct 1 I` 0 9CL,, I <br /> SIGNATUR DATE <br /> 3 U <br /> EH230038(re Iced 02/2 09) P7L <br /> __ 1 <br />