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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 /> AF EPA Site# Project Contact&Telephone#,A 14 '4 j P I_St Y-�,1-1.2 3(� <br /> C Facility Name S4 64,,5b 11ML Phone# <br /> � <br /> Address ,q S- KZ7rl-ZWi -LN. _ /6'D( CA, 9 S2Li -L- <br /> I Cross Street L G wER S, RAmL.,jT-o <br /> T <br /> Y Owner/Operator '•T-.,�� e tjg,5 r CO - -r co z t L Phone# )6 3- ' 9 t, - 700 <br /> o Contractor Name /�� �� L Phone# v7 -�ti �._ SCJ Z .Z <br /> N Contractor Address L �g'/O� CA Lic# L Class <br /> T �c� %D�c1gL�iC_ ,clf4 ' 1r ..3I� `� t�-�-�iu <br /> R Work ork Com , <br /> A �L7LCJ 1 �� -t��U�'� �iCJ ., p# LC. 7,1 - 'O. U <br /> TICC Technician's Certification Number Expiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved "S�-A,pproved with conditions ❑Disapproved <br /> L (Se ttachment With Conditions) <br /> A /to <br /> �l <br /> N Plan Reviewers Name Date Z b <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." <br /> Applicants Signature Title Date lR O <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_ ��I L TITLE✓62.L UT-- PHONE# <br /> ADDRESS, L(), 'i 11-tM,�J)4- - 3C)R�i4jk'_ G4 q/ SO <br /> n <br /> SIGNATURE ��— <br /> EH230038(revised 12/31/07) <br /> 1 <br />