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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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# L ;C3 407 <br /> A <br /> O Facility Name v7SPt `E"�Ovo Phone#",;i(:)q <br /> 1 Address �;�j f C LCL" r �4 <br /> T Cross Street �,. Sdc:LCL.tA_k. <br /> Y Owner/Operator px 0 Phone# :�S 3._ (o_ �(�n <br /> C Contractor Name 5•,w-\)6Ce , Phone# tt _ 3_ <br /> N is Contractor Address <br /> T C9�� �l� S� ('iN ��� CA Lic# ���� Class.'�.C'(¢((a([�� Z <br /> R <br /> A Insurer ' C;-3 :r"QVkLLC-L Work Comp# (DO;Lo •3100 ( <br /> cICC Technician's Name «� Expiration Date tC t 140 OCA <br /> T <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved KApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A nG <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 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 'j� <br /> Applicant'sSignature WC{.l:L`a(, V � Lu[:t• Title LC V ` T Date ala acv? <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. r ^ �i <br /> NAME MCLY4 111-u, W F t�l�titli of TITLE GqA 06CI �C uL�K.1�� PHONE# 6� �L�- � l.'��1 <br /> ADDRESS 06 Q_CL kLA- AL�k, lA <br /> SIGNATUREIA G/ulrZ, U, *-Lca_tU A-A� DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />